Strengthening Health Systems for Pandemic Preparedness and Other Emerging Challenges

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00:00 OK,

00:00 everyone,

00:00 to not penalize those who actually showed up on time too much,

00:03 we will get going here.

00:05 So welcome everybody to our,

00:07 uh,

00:08 February policy research talk.

00:10 We took a uh a break over the,

00:12 the

00:13 sort of end of year,

00:15 uh.

00:16 Festivities and we're now gearing back up.

00:18 We have an interesting slate coming up this spring,

00:22 um.

00:23 So,

00:23 without further ado,

00:24 let's me turn it over to Innermit Gill,

00:26 the senior vice president and chief economist of the World Bank,

00:29 who's gonna kick us off today.

00:31 Over to you,

00:31 Intermit.

00:33 Thank you,

00:33 Dion,

00:34 and I'm very,

00:34 very sorry again that I'm not there.

00:36 Uh,

00:37 so,

00:37 I really don't have anything important to say at the beginning,

00:40 other than

00:42 to say that I wasn't

00:43 at the World Bank for much of the time

00:45 of the pandemic.

00:47 And I always thought that the bank could have done a little better,

00:50 Dion.

00:51 I thought that,

00:52 I thought that I thought that the bank could

00:54 have done better in helping low and middle-income countries

00:58 actually tailor their responses uh

01:02 to the crisis,

01:02 both on the health side,

01:04 but also on the side of social protection,

01:06 as well as the economic response,

01:08 the fiscal

01:09 and monetary responses,

01:11 instead of copycatting advanced economies,

01:13 right?

01:14 So I was very interested

01:15 to know what Damien and Dana

01:18 were going to say about

01:20 the health part

01:21 of the response,

01:23 because I really don't know much about it.

01:25 Uh,

01:26 but I do know that among the people at the

01:28 bank who should be talking to us about these things,

01:32 these are probably the two best people.

01:34 Uh,

01:35 so Damien is

01:37 the acting manager of the human development team.

01:41 In,

01:42 uh,

01:42 the Development Research Group.

01:44 Um,

01:45 he,

01:46 um,

01:47 he actually has worked

01:49 on HIV interventions in several African countries.

01:53 Uh,

01:53 so he,

01:54 uh,

01:54 so it's really good that he turned his attention.

01:57 To the COVID response,

01:59 uh,

02:00 then,

02:00 uh,

02:00 uh,

02:01 the other person you're gonna hear from is Dina Ringold,

02:04 who is the director for strategy and operations for Human Development.

02:08 So she's a very important person

02:10 for making sure that we don't make the mistakes that we made in the past because.

02:15 Uh,

02:15 she actually covers both strategy and operations for human development.

02:19 Uh,

02:19 she also has been the regional director for human development in Africa,

02:24 and she actually worked also on the governance of service delivery.

02:28 So again,

02:29 The ideal person to

02:32 to speak about these things.

02:34 So I was struck,

02:35 by the way,

02:35 I was struck by the slides

02:37 that Damien sent,

02:39 and I don't want to steal his thunder,

02:41 but the thing that struck me on his last slide or last two slides was

02:46 there is no dichotomy between.

02:49 Good pandemic preparedness

02:51 and decent primary care,

02:53 so he says that Thailand and Vietnam

02:56 had

02:57 the best responses or among the best responses to COVID-19

03:01 because they had strong primary care systems

03:05 that the population trusted,

03:07 OK.

03:08 Uh,

03:08 so I,

03:09 I,

03:09 so I think that that seems to be,

03:12 that seems to be the key lesson that comes out of it,

03:15 but I'm sorry,

03:17 but I'm sorry to steal your thunder,

03:19 Damien,

03:19 by saying if that is indeed true,

03:21 I'm very sorry to steal your thunder.

03:23 But,

03:24 uh,

03:25 but if that isn't the case,

03:26 I'm going to listen and I'm going to,

03:29 uh,

03:29 change my tune at the end.

03:31 But over to you,

03:31 Damien,

03:32 and then to Dana.

03:34 And please chair the session,

03:36 Dean.

03:37 Sure,

03:38 no spoil but I won't be giving any spoil uh any spoilers,

03:42 just,

03:43 OK,

03:43 over to you,

03:43 Damien.

03:45 I

03:48 Thanks guys.

03:50 Thank you,

03:50 uh,

03:51 very much in the midst for these,

03:52 uh,

03:52 kind words,

03:54 and,

03:54 um,

03:55 I assume the microphone works well.

03:59 If that's the case,

04:00 uh,

04:00 let me start

04:01 and good afternoon,

04:02 everyone.

04:03 It's my pleasure to uh

04:05 present

04:06 this policy research talk entitled Strengthening Health Systems

04:10 for Pandemic Preparedness and Other Emerging Challenges.

04:14 And I want to start this talk

04:17 with,

04:18 um,

04:19 do you see actually.

04:22 Uh,

04:22 no,

04:23 there's,

04:24 uh.

04:27 Here,

04:27 OK,

04:28 thank you.

04:29 I want to,

04:29 uh,

04:30 start this talk with,

04:31 uh,

04:31 this

04:32 painting from Rembrandt.

04:34 Um,

04:35 you can see it in the Mauritzer in The Hague in the Netherlands.

04:38 The title is

04:39 The Anatomy Lesson of Doctor Nicholas Torp.

04:42 I want to start with

04:44 this painting,

04:44 not only as a note to my,

04:46 uh,

04:46 discussion

04:47 with from the Netherlands,

04:49 uh,

04:49 but also because I want to,

04:51 uh,

04:51 apologize to you because I'll

04:53 be talking a lot about

04:55 death and mortality.

04:57 Uh,

04:58 in Dermid,

04:59 um,

05:00 remember that,

05:01 that I've reminded you that I've

05:03 worked a lot on HIV AIDS.

05:05 When I was doing that,

05:06 people were teasing me

05:07 and were,

05:08 uh,

05:08 telling me,

05:09 Well,

05:09 Damien,

05:09 you always talk about death and sex.

05:12 I'm sorry,

05:13 but today I won't speak that much about sex,

05:15 but quite a lot about death.

05:16 So my apologies for that.

05:19 Uh,

05:19 more seriously,

05:20 the reason I,

05:20 I chose that pic that picture is that I want this

05:23 to start this,

05:24 uh,

05:25 talk

05:26 by doing some sort of,

05:27 um,

05:28 an anatomy of the pandemic,

05:30 the COVID-19 pandemic.

05:34 And so,

05:37 The outline of the talk is that I will start with

05:40 a retrospective look

05:42 at the COVID-19 pandemic.

05:45 I will

05:48 Uh,

05:48 raise some questions and lessons about

05:50 health investments

05:52 from the COVID-19 experience,

05:55 and then I will switch

05:57 to the current transition

05:59 in the burden of disease

06:01 that uh we are experimenting globally.

06:06 With the rise,

06:08 including the rise of non-communicable disease or NCDs.

06:13 And I will

06:15 try to look at 3 questions

06:17 basically how to invest in health

06:19 to minimize

06:20 amenable deaths.

06:23 I will talk about expanding health coverage,

06:26 but I will also stress

06:28 the importance of prevention and public health

06:30 measures

06:32 and the importance of quality of care.

06:35 Using the concept of effective coverage.

06:39 So I would like to start

06:41 with

06:42 Contrasting these two numbers

06:45 on the left we have 5.

06:48 9 million

06:49 deaths

06:50 and on the right we have 18.2

06:53 million deaths.

06:54 So what are these two numbers?

06:56 They come from

06:58 this paper published in The Lancet

07:00 by the COVID-19 excess mortality

07:03 collaborators.

07:04 5.9

07:06 million deaths.

07:08 Those are

07:10 official reported official COVID-19 deaths

07:13 during 2020

07:15 and 2021.

07:18 Where is 18.2

07:20 is the estimate these authors are doing

07:24 of the number of people who died during the same period,

07:26 2020,

07:27 2021.

07:29 Because

07:30 of the COVID-19

07:32 pandemic,

07:32 they are using.

07:34 Excess mortality methods to come to that estimate.

07:40 So what are excess mortality calculations?

07:44 They compare for the same period of interest the number of actual deaths

07:49 to the number of expected deaths

07:52 during the same period.

07:53 The number of expected deaths

07:56 is a projection

07:58 based on the number of deaths

07:59 in the immediately preceding years,

08:03 and they add to that a linear trend

08:05 because in aging populations,

08:07 the number of deaths tends to increase.

08:11 That's considered as the gold standard in the analysis of COVID-19 mortality.

08:16 And that

08:17 using these methods,

08:18 they obtained this number,

08:19 18.2,

08:20 which is three times

08:21 larger than officially

08:24 reported COVID deaths.

08:26 It's important to realize

08:29 that

08:30 these excess mortality estimates

08:33 represent a combination of

08:36 different effects.

08:37 The first one in blue

08:38 are

08:39 direct COVID-19 deaths,

08:41 deaths that are due to an infection with the virus.

08:44 To that,

08:46 we add the number in green,

08:48 which are the indirect COVID-19 deaths,

08:51 which might be due,

08:52 for example,

08:53 to congestions

08:54 of the health systems,

08:56 delay in care seeking people because people didn't want to go to the

09:00 health centers,

09:01 or

09:02 issues with mental health.

09:05 Now,

09:05 to that number,

09:06 you also need to subtract what is in

09:09 brown,

09:10 the averted deaths.

09:12 Those are deaths that would have taken place in the absence of the pandemic

09:17 but did not occur because of pandemic induced measures.

09:20 We can think,

09:21 for example,

09:22 during the lockdowns,

09:23 there might have been less

09:25 traffic injuries,

09:26 less violence,

09:28 or

09:28 other infectious diseases.

09:30 So it's important to realize that this excess mortality estimate.

09:34 Combine these three components.

09:39 So I said I will

09:40 discuss a lot about mortality,

09:42 but still

09:44 it's important to acknowledge that the impact of COVID-19

09:48 went well beyond mortality.

09:50 It included,

09:51 as I mentioned,

09:51 delayed care,

09:53 the mental health burden,

09:55 school closures,

09:56 learning losses,

09:58 lockdowns,

09:59 economic and political shocks.

10:01 I won't have the time to cover that,

10:03 but I wanted to acknowledge it.

10:06 So I want to

10:08 start by taking some lessons from this comparison between the official

10:12 COVID deaths

10:13 and the excess mortality.

10:16 So,

10:16 as I've said,

10:17 the,

10:17 the

10:18 excess mortality estimate

10:20 is more than 3 times higher than officially reported COVID-19 deaths.

10:25 That basically says that even in the 21st century,

10:29 our health and civil registration systems

10:32 are still not very good at measuring.

10:35 The impact of such a major health event

10:38 and that's certainly

10:40 it's a lesson,

10:42 that's an encouragement to step up our efforts to mainstream

10:46 civil registration

10:48 across the world.

10:50 It would have

10:51 benefits in terms of

10:53 measuring the impact of future pandemics,

10:56 but it has also

10:57 many benefits beyond an accurate measure of mortality.

11:00 It's important

11:02 to register every birth so that the children can benefit

11:05 from health and social services.

11:09 Then using

11:11 these numbers,

11:13 I will

11:13 quickly try to see how the deaths from COVID-19 were distributed around the world

11:19 and try to ask how big of a number

11:21 is 18.2 million.

11:23 Obviously it's a big number,

11:24 but I will compare it to

11:26 past events

11:27 as well as compare it to other

11:29 recent health events.

11:32 So this is

11:33 a map showing the distribution of excess mortality.

11:38 Across the world

11:40 Only in the country

11:41 where us where

11:44 using vital statistics allow

11:46 such a calculation.

11:47 So you see all the numbers

11:49 with the gray shaded

11:53 color

11:54 is basically where such a calculation is not possible.

11:57 But otherwise,

11:59 looking at the colors and realizing that the

12:02 closer you are to the dark red.

12:05 Color,

12:07 the higher the mortality rate,

12:09 we see that mortality using

12:11 excess mortality numbers was highest in Russia

12:14 and some of the

12:18 Eastern European countries.

12:19 It was also quite high in South Africa

12:21 as well as in Brazil,

12:24 Mexico,

12:24 and Ecuador.

12:27 Coming back to the paper

12:29 I mentioned earlier

12:31 in The Lancet,

12:33 what they've done,

12:34 so

12:35 where there was vital statistics

12:39 available to do the calculation,

12:41 they are using that.

12:43 And otherwise in the other countries that were shaded in gray in the previous map,

12:47 they've done a modeling exercise.

12:49 And here again,

12:50 the closer you are to dark orange,

12:52 the higher the mortality rate.

12:56 And

12:58 the green color is lower mortality rate,

13:00 so we see low mortality

13:02 in Australia,

13:03 New Zealand,

13:04 China,

13:04 and some African countries,

13:07 and higher mortality again in Russia,

13:10 Eastern Europe,

13:11 the southern corner of Africa.

13:14 Latin America,

13:15 especially Peru and Bolivia,

13:17 as well as Mexico.

13:21 So if we take these numbers from the same paper and rank them by our

13:25 World Bank

13:26 regions

13:27 and add a category for high income country,

13:30 this is what we get in terms of excess mortality per 100,000 people.

13:35 In East Asia,

13:37 excluding China and and sub-Saharan Africa,

13:40 mortality was lowest.

13:42 Then comes the group of

13:43 high income countries,

13:45 and then

13:46 not very much higher,

13:47 MA,

13:48 South Asia,

13:49 and quite higher.

13:51 Latin America and the Caribbean

13:53 as well as ECA.

13:58 So in a paper that we published with Gabriel whoisi and other quarters,

14:04 colleagues at the bank,

14:05 we use

14:07 both official COVID deaths

14:09 on the left

14:11 and excess mortality estimates on the right

14:14 to look at

14:15 how COVID-19 mortality.

14:19 Was

14:20 distributed by age groups,

14:23 and we've ranked

14:24 the countries in

14:26 descending order of income with

14:29 middle income at the top and richer country,

14:32 high income countries at the bottom.

14:35 We use colors to show,

14:37 uh,

14:38 so all

14:39 the share of death

14:40 among individuals younger than 65

14:43 is in.

14:45 Orange or brown,

14:47 so working age people,

14:48 the share of deaths

14:50 among

14:51 older people older than 65 is in

14:55 different shades of

14:57 green,

14:57 and what we see is that in the middle income countries,

15:01 the share

15:04 of death at younger age is higher.

15:07 And that's controlling for the age structure of the population.

15:11 So basically,

15:11 mortality affected more working-age

15:14 individuals

15:15 in

15:17 middle-income countries than in high income countries.

15:21 I want to step back a little bit and look in history.

15:25 And compare

15:27 the COVID-19 pandemic

15:28 with the

15:29 Spanish flu or Spanish influenza that took place

15:33 about 100 years before

15:35 COVID-19,

15:37 between 1918 and 1920.

15:40 So on the left here you have the two numbers I've already

15:44 given you

15:45 5.9,

15:46 18.2 million deaths,

15:47 the two estimates.

15:49 It's quite difficult to estimate mortality from the Spanish flu,

15:53 but historians.

15:54 Agree on a central estimate

15:57 of about 50 million

15:59 individuals

16:01 and the period was about

16:03 the same length

16:04 and then that's the number in the middle

16:07 and then the two numbers on both sides are the low and the high

16:13 estimates from historians.

16:15 So of course

16:17 the world population was much smaller 100

16:20 years ago.

16:21 It was estimated to be about 1.9 billion and currently we are about 7.9 billion.

16:27 So

16:28 to do

16:29 correct

16:30 comparison,

16:31 you should divide the previous number by the

16:33 size of the population,

16:35 which I have done here.

16:36 And we see

16:37 that

16:39 the difference is even starker in terms of mortality rates.

16:43 The mortality rates

16:44 were much higher.

16:48 100 years ago.

16:51 So,

16:53 of course,

16:54 we should expect that.

16:55 Because

16:56 we should have done better because over the last 100 years there has been a

17:00 tremendous progress

17:02 in life expectancy as

17:05 shown from this picture just showing

17:08 life expectancy over the last 100 years.

17:11 The dark green

17:14 line is for the world as a whole,

17:16 and then you have this different line

17:19 for each continent.

17:21 And we see the levels are different,

17:23 but the trend is the same with

17:28 Gradual increase

17:30 and substantial increase in life expectancy.

17:33 So we should have done better.

17:35 But even accounting for that,

17:37 I would like to argue that we did

17:39 better

17:40 than 100 years ago,

17:41 and I would like to argue that the vaccine played an important role

17:45 in this.

17:46 So let's

17:47 remember

17:48 from the day the scientists.

17:52 Performed the genomic sequencing of the virus

17:55 to the first approval of a vaccine,

17:57 there were only 326 days.

18:00 That's very little by historical standards.

18:04 So in a paper in

18:07 The Lancet,

18:08 Watson and Coulter

18:09 tried to estimate

18:11 the global impact of the first year of COVID-19

18:15 vaccination,

18:16 looking at the period between December 2020

18:19 and December 2021.

18:23 Again,

18:23 they use the two methods that I've described before,

18:26 using the official

18:28 reported COVID deaths as well as the

18:31 excess mortality estimates.

18:35 Using the first

18:36 method,

18:37 the officially reported COVID-19 deaths,

18:39 they estimate that vaccination prevented 14.4 million

18:44 additional deaths.

18:45 The second,

18:46 using the second method,

18:47 they estimate is higher,

18:49 19.8 million additional deaths.

18:53 So basically,

18:53 vaccination more than halved

18:56 COVID-19 mortality

18:58 despite being introduced one year after the start

19:01 of the pandemic.

19:04 Another way to look at

19:07 the benefit of vaccination is to do

19:10 returns on investment calculation.

19:13 That's what SAR

19:14 and others are doing for the New York City COVID-19 vaccination campaign.

19:19 Looking at the period between December 2020 and January 2022,

19:25 they first calculate and estimate

19:27 the cost,

19:28 the direct cost of the vaccination campaign,

19:30 also the indirect,

19:32 including

19:33 time lost

19:34 to go for vaccination,

19:35 time lost due to side effects of vaccination.

19:38 Their estimate

19:40 is $4.8 billion.

19:43 Then they do two calculations for the benefits.

19:46 The first one is just adding.

19:48 The

19:49 direct and indirect healthcare costs.

19:53 And that they come to close to 28.

19:58 billion dollars

20:00 and.

20:02 Later

20:03 next,

20:03 they also want to account for the lives saved.

20:07 Using the

20:08 value of a statistical life methodology

20:11 that is developed by economists to calculate

20:14 how much people would be willing to live one more year

20:18 and doing this,

20:20 they

20:20 come to additional saving of $26.3 billion.

20:26 So

20:27 they calculate

20:29 two

20:30 returns on investment,

20:32 including the value of the mortality saved.

20:36 $1 spent saved $10.19 that's a return on investment of

20:42 1,019%,

20:44 and without

20:45 the

20:46 life saved,

20:47 $1 spent saved 4.27.

20:52 Dollars that are returns on investment of $427 a point of comparison.

20:58 The return on investment in the technology sector in the US was 16%

21:03 in 2022.

21:05 I should add that this calculation

21:07 doesn't account for the potential cost of lockdowns,

21:11 school and business closures

21:13 that could have occurred in case of no vaccination,

21:15 so it's

21:16 probably

21:17 an underestimate.

21:20 So I think it's fair to say that COVID-19

21:23 vaccines were a game changer.

21:26 But we should acknowledge that globally

21:29 we encountered problems with equitable manufacturing and distribution.

21:34 My colleague Tristan Reed gave a policy research talk

21:37 2 years ago

21:38 about this topic,

21:39 so I will,

21:39 I will not

21:41 cover it.

21:41 I would refer you to it.

21:43 And also,

21:44 as we

21:46 campaigned for vaccination,

21:48 we encountered in many countries vaccine hesitancy,

21:52 which is linked to the trust in the health system.

21:55 Which if not addressed,

21:56 might have lingering effects,

21:59 including for other diseases.

22:00 So it's important to verify whether

22:03 and to what extent

22:05 vaccine hesitancy has spread.

22:08 To other well established vaccines,

22:10 including childhood immunization,

22:12 for example,

22:12 in December 2023,

22:15 there was an outbreak of measles in Kazakhstan,

22:19 and there is some indication

22:21 that this might link to

22:23 a

22:23 lower rate of vaccination for measles among children.

22:28 So,

22:30 I will,

22:30 as I move

22:32 towards the end of this retrospective look at the COVID-19 pandemic,

22:35 I want to draw

22:36 three

22:37 main lessons.

22:38 The first one

22:40 is a very basic one,

22:41 a very simple message,

22:43 which is it pays to invest in health.

22:45 I've

22:46 given you some examples.

22:48 There's something we knew

22:49 at the World Bank,

22:51 at least since the World Development Report in 1993.

22:54 Entitled Investing in Health.

22:57 And

22:59 We can debate

23:00 whether the World Bank could have done better,

23:02 but our institution delivered on this

23:04 premise

23:05 from April 2020 to March 2021.

23:09 The World Bank Group committed over $200

23:12 billion

23:13 to public and private sector clients to fight

23:17 the impact of the pandemic.

23:19 Second lesson I want to take is that

23:22 government

23:23 play an important role,

23:24 an important role.

23:26 But individual behavior still matters a lot,

23:29 so the government played a role in

23:32 Establishing and enforcing lockdowns.

23:37 In some cases maybe not enough in providing social support

23:41 during those lockdowns,

23:42 in maintaining essential services

23:46 during

23:47 the crisis,

23:48 even

23:50 if those services were under stress.

23:52 I'm thinking,

23:53 of course,

23:53 first and foremost at the hospitals

23:55 and also in purchasing the vaccine and distributing them.

23:59 The private sector also played a role.

24:02 I'm

24:03 thinking here about the development and the manufacturing of vaccines,

24:07 but we've seen that individual behaviors still matter a lot.

24:11 Most of us want to be vaccinated,

24:13 but as I've discussed,

24:14 there was also vaccine hesitancy.

24:17 Most of us followed lockdowns and mask mandates.

24:20 But there was also some resistance.

24:23 For example,

24:23 this paper by

24:25 Abaluk and others

24:26 shows how interventions

24:28 to persuade people to wear masks were important in Bangladesh.

24:34 Third lesson

24:36 is that trust matters.

24:38 So I'll illustrate this

24:40 using first a paper by Asano and others.

24:43 They use

24:44 people voice surveys,

24:45 phone surveys

24:47 in 14 countries ranging from low to high income.

24:51 They find that greater healthcare use,

24:54 having a regular and high quality provider,

24:57 using other preventive services,

24:59 confidence in the health system and in the government,

25:02 positively correlated with COVID-19 vaccination.

25:06 There is also some evidence

25:08 that countries which had been confronted and responded to previous

25:12 epidemics

25:13 such as the SARS epidemic in East Asia in 2003

25:17 and the Ebola epidemic in West Africa

25:20 between 2014 and 201616 were better prepared.

25:24 There is also

25:26 some evidence about the role of politics

25:28 in building trust

25:30 or

25:31 not building it.

25:32 I'll mention

25:33 two examples without going

25:35 too much in details.

25:36 I'll mention Brazil

25:38 and the

25:40 United States.

25:42 So let me finish about COVID-19 by just giving you some perspective about

25:48 That

25:49 famous number of 18.2 million deaths

25:51 that was for the period 2020 to 21,

25:54 2 years for COVID-19.

25:57 If we compare with HIV AIDS over a much longer period,

26:00 more than 30 years

26:02 between 1991 and 2022,

26:04 the estimated

26:06 number of deaths

26:07 is 14.4 million.

26:09 And then Ebola that I just mentioned

26:12 in 2014 to 2016.

26:15 The death toll was 11,325 individuals,

26:19 and SARS in East Asia in 2003

26:22 was 774.

26:27 No,

26:28 I want to take

26:30 this number

26:32 of COVID-19 estimated excess deaths

26:36 and just focus on the excess debt in

26:38 low and middle income countries.

26:41 That's the number here on the top on the right is 15.6 million

26:45 for the two years,

26:46 2020

26:47 and 202021.

26:48 And I will pivot to other

26:51 disease by

26:52 comparing this number that happens to be the same by

26:56 chance.

26:57 To the

26:58 number of total avertable deaths in low and middle income countries,

27:03 so those are deaths that could have been avoided.

27:06 Uh,

27:06 in

27:07 the year 2016,

27:08 just,

27:09 uh,

27:10 one year,

27:10 but it's

27:12 just before COVID and it happens to be the same number.

27:14 So look,

27:15 let me take that number

27:17 and further

27:19 decompose it.

27:20 That's what I mean,

27:20 that's what

27:21 Margaret Kirk and others are doing in this paper published

27:25 in The Lancet.

27:26 So they take this number of

27:29 total

27:30 avertable deaths,

27:31 15.6 million for 2016.

27:34 What they first do

27:36 is they compose that number

27:37 between deaths that are

27:39 amenable to healthcare

27:41 that could

27:42 have been treated in healthcare.

27:44 They come to the number of 8.6 million or 55%.

27:48 And then,

27:49 and then that's prevented.

27:52 Sorry,

27:53 deaths preventable by public health intervention,

27:57 that's 7 million

27:58 or 45%.

28:01 Then

28:02 the number of deaths amenable to healthcare,

28:05 they further divide it into two categories

28:08 the deaths due to the non-utilization of health services.

28:12 That's

28:13 3.6 million or 23%,

28:17 and the deaths due to use of poor quality services,

28:20 that's 5 million

28:22 or 32%.

28:24 So I'm not going to go too much into the detail of

28:28 how they are doing this.

28:29 It's another use

28:30 of excess mortality.

28:33 What they are doing,

28:33 they're using data from the 2016 Global Burden of Disease study.

28:39 And they calculate mortality amenable to personal healthcare

28:44 for 61 SDGs,

28:47 medical conditions,

28:48 and they compare the case fatality.

28:51 The case fatality

28:52 is the number of deaths.

28:54 Divided by the number of people suffering from a specific disease,

28:58 they

28:59 compare this case fatality between each low

29:02 or middle income country

29:04 with the corresponding case fatality

29:07 for 23 high income reference countries with a strong health system.

29:11 They further used data on healthcare utilization from population surveys

29:16 to separate the deaths due to non-utilization

29:19 and deaths due to poor quality.

29:23 If we take those numbers.

29:26 And

29:27 divide them by region.

29:29 This is what

29:31 the picture we are getting.

29:33 So in dark blue,

29:35 we have the deaths

29:37 per 10,000 people due to low quality of healthcare.

29:40 In light blue,

29:41 we have the deaths due to non

29:44 utilization of healthcare.

29:46 And in yellow with deaths due to insufficient prevention,

29:50 issues with individual behaviors,

29:53 environment,

29:53 or lack of preventive care.

29:57 There are two main messages

30:00 from

30:01 the paper.

30:02 The authors,

30:02 they

30:03 mainly focus on

30:06 quality of care.

30:06 They say that in low income countries,

30:09 expanding healthcare coverage does not necessarily result

30:13 in better outcomes,

30:15 even for conditions highly amenable to medical care,

30:18 and therefore health system quality must improve.

30:22 I fully

30:23 agree with that

30:25 message,

30:25 but I would,

30:27 that quality of care matters,

30:28 but I would like to add also the one that prevention

30:31 and other public health intervention

30:33 matter.

30:35 So

30:36 to finish with the estimate from this paper,

30:39 here is a map showing.

30:42 In the world

30:43 where the mortality due to poor healthcare quality

30:47 is highest,

30:49 so the countries in

30:51 gray are the 23 reference countries with strong health system,

30:56 and then the

30:57 closer you are to the dark blue color,

31:00 the higher the mortality due

31:02 to poor quality of care.

31:04 We see that's highest in many countries in Africa,

31:06 especially.

31:07 In countries in West Africa

31:10 and Central Africa,

31:11 it is also quite high

31:13 in Afghanistan,

31:14 Pakistan,

31:15 and India in South Asia.

31:20 So no

31:22 Moving to

31:23 other disease than COVID-19,

31:25 it's important to

31:28 realize that COVID-19 occurred in the middle

31:30 of a transition in the burden of disease.

31:33 Overall,

31:34 the world experienced

31:36 a rise in the.

31:37 Of noncommunicable diseases,

31:41 also called chronic disease

31:43 such as cancer,

31:44 diabetes,

31:45 hypertension,

31:46 heart condition,

31:47 and others,

31:49 their characteristics are that

31:51 they are of long duration

31:53 and

31:54 for successful treatment,

31:56 it's important

31:57 to have early detection.

31:59 NCDs will become even more prevalent with aging populations.

32:04 Non-communicable disease kills 41 million people each year.

32:08 That's equivalent to 74%

32:11 of all deaths globally.

32:12 I'm not,

32:13 I don't like too much that statistics because

32:16 Unfortunately we know we'll all

32:18 die

32:20 and

32:21 we'll all die of something,

32:22 but I think it's

32:23 more

32:25 important to focus on

32:27 premature deaths.

32:28 So the second statistic I think is

32:31 more

32:33 telling.

32:33 Each year 17 million people die from

32:37 an NCD

32:38 before age 70,

32:41 and 86% of these premature deaths occur in low and middle income countries.

32:46 As I sketch

32:48 this transition in the burden of disease,

32:50 I also want to mention the consequences of climate change on health,

32:53 including air pollution,

32:55 droughts,

32:56 heat waves,

32:56 etc.

32:57 I won't have the time to discuss this

33:00 in detail

33:01 today,

33:02 but I wanted to acknowledge it.

33:05 So let me sketch this transition in the burden of disease using

33:09 3 of these graphs.

33:11 Here we are looking

33:13 at low income countries and we are not looking at deaths this time.

33:18 We are looking at

33:20 DALIS,

33:20 which is the acronym for disability adjusted life years.

33:24 So it's the number of years lost because of a disease and it's adjusted

33:29 for the years you live with a disability because of the disease.

33:33 It's millions,

33:33 we go to the period from 1990 to 2019.

33:37 I'm not going to go

33:39 over the list of diseases,

33:40 but on the left we have the communicable disease,

33:44 including also the maternal disorders,

33:46 neodental disorders,

33:48 and others.

33:49 On the right we have the communicable disease that I've mentioned before,

33:53 hypertension,

33:54 cancer,

33:54 cardiovascular disease,

33:56 diabetes,

33:57 etc.

33:59 What we see in low income countries is over time

34:02 a decline in

34:03 the share

34:05 of the burden of disease from communicable disease and a gradual increase

34:09 from

34:10 The

34:11 NCD on the NCD side,

34:12 it's still important to note

34:14 that in the low

34:16 income countries,

34:17 the total number

34:18 is still higher

34:20 on the communicable

34:21 disease side.

34:22 So

34:22 I don't want to discount the importance

34:24 of communicable disease,

34:26 especially

34:27 in low income countries,

34:28 but the trends are

34:30 clear.

34:32 Same picture for lower middle income countries.

34:35 The trends are the same decline on the communicable disease side,

34:41 increase on the

34:43 NCD side.

34:44 Here,

34:44 the total number by the end of the period is actually

34:47 higher

34:48 on the NCD.

34:53 And then finally the picture for upper middle income countries,

34:57 you see a stark decline

34:59 in the share

35:01 of the communicable disease in

35:04 the

35:05 lost dallies

35:06 and an increase

35:08 in the

35:10 in the numbers and the share

35:12 for the NCD.

35:16 So of course those numbers were

35:18 stopped in 2019 before COVID.

35:21 I've just said,

35:22 you know,

35:23 a rise in the share of

35:26 non-communicable disease

35:28 and COVID-19 was an imminently communicable disease,

35:31 a new one,

35:32 so that sort of changed the picture,

35:34 of course,

35:35 at least for two years.

35:38 But it is also important to note that there are

35:42 important interaction between COVID-19 and.

35:45 Non-communicable disease.

35:47 People

35:48 suffering from NCDs are more vulnerable when they are infected

35:52 by COVID-19,

35:53 more likely to end up in the hospitals or to die.

35:57 We are learning about long COVID that

36:00 might

36:00 be a new chronic condition.

36:02 We've seen

36:03 the

36:04 health and mental health consequences of the lockdown

36:07 as well as the non-health consequence of the lockdown

36:11 on poverty

36:12 and education.

36:15 So COVID-19.

36:17 I've tried to argue,

36:18 reminded us

36:19 that it pays to invest in health,

36:22 but what I'd like to do

36:23 is to spend the rest of my time

36:26 trying to

36:27 ask how best to invest

36:30 in health,

36:31 given the transition in the burden of disease

36:34 that I just

36:35 presented.

36:38 So I think the transition in the burden of disease.

36:41 Stress the importance of prevention first.

36:44 Prevention is more effective in terms of disability adjusted life years.

36:49 That is

36:50 saved,

36:51 and it's also more cost effective than treatment.

36:54 Prevention

36:56 can take place at two levels.

36:57 First,

36:58 at the population level.

37:00 And then at the interaction between the population

37:03 and the health systems

37:05 where both

37:06 the demand and the supply side can play

37:09 a role.

37:11 So let's first think about the intervention at the population level,

37:14 so-called public health intervention.

37:17 One first set of interventions

37:20 aimed at reducing risk factors.

37:21 We're thinking about reducing

37:23 smoking,

37:24 alcohol and drugs consumption,

37:27 unsafe sex,

37:28 bad eating

37:30 and drinking habits.

37:32 Or they could also increase

37:34 good habits,

37:34 good health habits such as

37:36 exercise,

37:37 healthier nutrition.

37:39 They could encourage hygiene and for example,

37:42 mask wearing during

37:43 pandemics.

37:44 It's important to note that this type of

37:46 intervention ever benefits not only for the individual,

37:49 but also for others since there is a

37:52 positive externality.

37:54 There is also

37:55 intervention

37:57 to reduce

37:59 environmental exposure.

38:00 We are thinking about

38:01 reducing unsafe water,

38:04 pollution,

38:04 etc.

38:06 In terms of pandemic preparedness.

38:10 Epidemiologic surveillance is very important,

38:12 being able to detect when

38:14 a new virus

38:16 might

38:17 occur,

38:17 a new outbreak of a known virus might

38:21 occur,

38:21 and for that,

38:22 the concept of one health is important.

38:24 One health

38:25 is basically looking at the same time

38:28 at human and animal health and their interaction.

38:31 We know that many

38:32 of the recent pandemics were triggered

38:35 when a virus jumped from

38:38 animals to humans.

38:40 So these interventions are mainly on the demand side.

38:44 It's first

38:46 about providing information.

38:48 When it's not sufficient,

38:50 Financial incentives

38:52 could play a role.

38:54 We can think of

38:55 cash transfer potentially,

38:57 but I would argue that when feasible,

38:59 especially for bad habits,

39:02 taxation.

39:04 the most efficient instrument

39:07 we've seen that

39:08 tobacco taxation

39:09 was very instrumental in reducing

39:12 smoking rates.

39:13 There are many experiments currently

39:16 with taxation,

39:17 for example,

39:18 for

39:19 sugar sweetened beverage.

39:21 There is also some role on the supply side

39:26 for supply side intervention,

39:28 for example,

39:29 the vaccination campaigns.

39:32 Prevention also occurs at the interaction between

39:37 population and health system and where both

39:39 demand

39:40 and supply side can play a role.

39:42 We're thinking about

39:44 antenatal care,

39:45 stressing how important it is for pregnant women to come to regular

39:50 checkup before they deliver.

39:53 Immunisations.

39:55 I've mentioned the COVID vaccine,

39:57 but there are also all the

39:59 child immunization or the flu vaccines for adults.

40:01 I want to take this opportunity

40:04 to celebrate the introduction

40:06 of the new malaria vaccine

40:09 for the first time in the official child

40:11 immunization calendar in Africa that was in Cameroon

40:15 at the end of last month.

40:17 Also very important is the early detection of non-communicable disease

40:22 such as cancers,

40:23 hypertension,

40:24 etc.

40:26 It's important also to address antimicrobial resistance,

40:29 which can be triggered by misuse or overuse

40:33 of antimicrobial drugs.

40:37 So here again we need information on the need of preventive care.

40:41 People

40:42 should know that it's important,

40:43 for example,

40:44 to

40:44 do regular screening

40:46 for chronic disease.

40:49 But when it's not sufficient,

40:51 financial incentives could be used,

40:53 for example,

40:53 cash transfer,

40:55 but sometimes simpler and cheaper intervention

40:58 such as personalized invitation can be as

41:01 cost effective.

41:02 So I'll give you

41:03 one example from a study we conducted with

41:06 World Bank colleagues

41:07 in Armenia

41:09 where we compared

41:11 personal invitation and cash voucher

41:13 to encourage hypertension and diabetes screening.

41:17 We

41:18 on the left here,

41:20 so we are looking at individuals who are aged 35 to 68,

41:24 that's the age when people are supposed to do a yearly screening for

41:29 for hypertension and diabetes in Armenia.

41:32 We looked at people who are not

41:34 been

41:35 screened in the last year.

41:38 And we followed them over six months in the comparison group,

41:41 just 3.5% of people screened.

41:46 In orange you see people who had received a personalized invitation,

41:50 with an invitation signed by a doctor,

41:53 by their doctor,

41:54 telling them

41:55 how,

41:56 where and when

41:58 and under which condition they could come

42:00 for the screening,

42:00 and that the screening was free.

42:02 You see that the screening rate

42:05 increased by 15% points to

42:07 18.5%.

42:09 And then there was another

42:11 intervention.

42:12 Where

42:13 to the invitation we added a $10

42:17 conditional voucher.

42:18 They could redeem the voucher

42:19 in pharmacy

42:21 chains

42:21 and basically we told them if

42:25 if and only if you are coming for

42:29 the

42:30 screening,

42:31 we will give you after that

42:33 this $10 voucher and we see that the screening rates

42:37 sort of

42:39 Increased by another

42:41 15% points,

42:45 so the impact was larger if you add the conditional voucher,

42:49 but when we looked on the right

42:52 at the average cost per person screened.

42:55 There we see that because the conditional voucher of course

42:59 cost

42:59 $10 and you needed to bring it,

43:02 the average cost per person screened was similar above

43:06 about $60 a little bit more than $60 per individual.

43:11 I went here to make an aside about

43:14 obesity,

43:16 so we all know about the new drugs

43:19 made from semaglutide,

43:21 the brand names Ozempic and Wegovi,

43:23 and a fair question is whether they are

43:25 a game changer.

43:27 So

43:28 we know obesity is important and it's killing many people,

43:33 not only

43:34 in rich countries.

43:35 On the map here on the left,

43:38 you see the share of deaths attributed to obesity in 2019.

43:43 And the closer you are to the

43:45 red color,

43:47 the higher it can go up to 30% in some of the

43:51 countries in the Arab world,

43:52 but in many other countries,

43:53 we have a large

43:54 share of

43:55 deaths

43:56 attributable to obesity.

43:58 So it's an

43:59 important issue in many countries in the world.

44:02 But the current prices

44:03 are quite high.

44:04 They are between $215 and $700

44:07 a month,

44:08 and

44:09 you could say that's way too expensive for low and middle income countries.

44:13 Isn't it better to focus on prevention

44:15 and behavior change?

44:18 My answer is maybe,

44:19 but that debate reminds me of a debate that took place when I joined the bank

44:24 around the

44:25 the early 2000s,

44:27 where

44:28 the same reasoning was made for

44:30 antiretroviral treatment

44:31 for HIV AIDS patients.

44:33 The prices were

44:34 sky high and people were saying.

44:37 Low and middle income countries cannot afford that.

44:40 We should focus on prevention and behavior change.

44:44 Turns out the price went down

44:46 and no

44:47 anti-retroviral treatment is available

44:49 everywhere.

44:51 And it's estimated to have saved 18.6 million lives

44:55 between 200 and 200

44:58 and 2021.

45:00 No,

45:00 I will

45:02 finish

45:03 this talk by looking at the quantity

45:06 and the quality of healthcare.

45:08 Um,

45:09 some of the

45:10 dividends I will take is coming from a policy research report

45:15 that we wrote with many authors

45:18 here at the bank,

45:19 uh,

45:20 entitled Improving Effective Coverage in Health

45:23 Do Financial incentives Work.

45:24 I

45:25 presented with Eugenie Camp Paldi.

45:28 Report in a policy research talk in May 2022.

45:32 So if we look,

45:33 if we think about the quantity of healthcare or health coverage,

45:37 it's first a supply side issue.

45:39 We need

45:40 the right number of health centers,

45:42 of doctors,

45:42 nurses,

45:43 the right equipment,

45:45 but even when

45:47 centers are well staffed and well equipped,

45:50 staff must provide sufficient effort.

45:53 It depends on their intrinsic motivation,

45:55 but also on their

45:56 extrinsic motivation,

45:58 their salaries,

45:59 but also the potential role of performance-based financing or PBF.

46:04 Our institution,

46:05 the World Bank,

46:05 has

46:06 invested

46:07 substantially in that reform,

46:09 and that report

46:11 is looking at the evidence.

46:13 I won't go into the detail,

46:15 but

46:16 note that even if

46:18 you make an effort on the

46:21 supply side,

46:22 there is also the need for patients to come

46:25 to receive healthcare,

46:27 including for preventive care.

46:29 So for uncomplicated case,

46:31 financial incentive for patients

46:33 to visit primary care facilities

46:36 could be used and have been used.

46:38 So that's what we are

46:40 looking in the report.

46:42 In that exercise,

46:43 we compared financial incentives offered to patients to visit clinics

46:48 on the demand side.

46:50 We compare them to incentives offered to providers

46:53 to increase and improve service delivery,

46:56 uh,

46:56 like performance-based financing on the supply side.

46:59 So we did this exercise for

47:01 maternal and child health services.

47:03 What do you have in this?

47:05 Graphs on the right side you have a demand side intervention,

47:10 conditional cash transfers.

47:12 On the left side you have a supply side intervention,

47:15 performance based financing for

47:17 health providers.

47:18 In the middle

47:20 is a voucher which is a hybrid between the two.

47:22 The patient receives a voucher that they can use to receive free services,

47:27 and then the

47:29 health center.

47:30 Cash the voucher.

47:31 We look at 6

47:34 maternal and

47:36 child health services,

47:37 modern family planning,

47:39 facility delivery,

47:41 4 antenatal care visits,

47:43 1 postnatal care visit,

47:45 maternal tetanus vaccination,

47:46 and full child vaccination.

47:48 What do we see overall

47:51 positive

47:51 effects most of the time,

47:53 but not always

47:54 statistically significant as indicated by

47:58 the stars.

48:00 But the effects are overall a little bit modest,

48:03 and if you look at the point estimate.

48:06 If anything,

48:07 the point estimates are somewhat larger on the demand side,

48:10 the CCT side,

48:12 and the vulture side than on the supply side.

48:15 Let me then look at

48:18 quality of care,

48:19 using the concept of effective coverage.

48:23 It's a concept that requires that everyone in

48:25 need of a particular health service is getting it

48:28 in a timely manner and at the quality necessary

48:31 to obtain the desired effect

48:34 and the potential health gain.

48:36 So it's basically we go from utilization,

48:39 which is the percentage of the population using a service.

48:42 To coverage which is the,

48:44 which is the population

48:45 in need using a service

48:48 to effective coverage,

48:50 percentage of the population in need

48:52 using a service and getting the optimal treatment.

48:55 I'll show you using an example.

48:58 The example of hypertension in 5

49:01 East Asian countries

49:02 that

49:03 you can miss an important part of the picture if you only look at quality or quantity.

49:09 So we start with quantity or coverage.

49:12 So we are using

49:16 WHO step-wise survey.

49:17 We are looking among the people who suffer from

49:20 hypertension.

49:21 The survey measured their blood pressure,

49:23 the percentage

49:25 which receive treatment,

49:26 and you see it varies a lot.

49:28 It's quite high in Cambodia and Vietnam,

49:30 but it's much lower in Mongolia,

49:31 Myanmar,

49:32 and Timor-Leste.

49:33 Next

49:34 we look in orange

49:36 at quality.

49:37 Quality

49:38 is

49:40 the

49:43 Among those who receive treatment.

49:45 The percentage with their high plantation under control,

49:48 and here the picture

49:49 is somewhat flipped

49:50 with better

49:51 results in terms of quality for Myanmar and Timor-Leste.

49:54 But I would argue that

49:56 the two numbers

49:57 are

49:58 misleading or not sufficient.

50:00 What you need to do

50:02 is multiply the two numbers,

50:04 get their product

50:05 to get at

50:06 effective coverage.

50:07 That's what we do here

50:09 when we

50:10 multiply

50:11 the two numbers.

50:12 We get the number in

50:14 gray.

50:15 And here clearly

50:17 the numbers are fairly low in Cambodia and Vietnam.

50:19 It's between 10 and 20%,

50:21 and it's below 10%

50:23 in Mongolia,

50:23 Myanmar,

50:24 and Timor-Leste.

50:26 So to finish with

50:28 quality of healthcare and

50:31 effective health coverage again,

50:32 it's first

50:34 a supply side issue.

50:35 You need to train high quality doctors and nurses.

50:38 You need high quality equipment.

50:40 But even when well trained staff and well equipped health centers are available,

50:45 staff must provide sufficient effort to reach

50:48 minimum quality.

50:49 Again,

50:50 it depends on intrinsic and extrinsic motivation,

50:53 and

50:54 performance-based financing might play a role,

50:58 but patients could also be better informed of what minimum quality standards are.

51:04 And which facilities satisfy them

51:06 so we could think of information interventions.

51:09 Now let me finish by

51:11 um.

51:13 Repeating the first,

51:14 the three lessons

51:15 I took from the COVID-19.

51:18 The first is a simple message that it pays to invest in health.

51:21 The second one is that government play

51:23 an important role,

51:24 but individual behavior still matters.

51:27 And the third is that trust matters.

51:30 So here is

51:32 the thunder that Imit stole

51:34 that there is no dichotomy between pandemic preparedness and primary care.

51:39 Thailand and Vietnam

51:40 offered one

51:41 of the best.

51:43 Response to COVID-19

51:45 because they had a strong primary care system

51:48 in which the population trusted.

51:50 My main message in terms of

51:52 universal health coverage.

51:54 Is that the quantity and the coverage of healthcare providers remains important.

51:59 But prevention and public health measures could help avoid a large share

52:04 of the burden of disease,

52:06 especially with the growing share of NCDs,

52:08 and that quality of care

52:10 is at least as important as quantity.

52:13 And I'll finish with this

52:14 main policy message.

52:16 Prevention is key,

52:18 especially but not only given the rise of NCDs,

52:22 the importance of vaccination,

52:24 of public health measures such as information,

52:26 but also taxes.

52:28 On

52:29 unhealthy behavior

52:30 and the importance of early screening.

52:33 Quality of care must be an essential component of universal health coverage,

52:38 and quality of care builds trust in health systems.

52:42 And finally,

52:43 strong primary healthcare systems

52:45 are the foundation

52:47 of pandemic preparedness.

52:49 Thank you very much.

52:58 Thank you,

52:59 Damien.

52:59 That was an incredible amount

53:01 of

53:01 of

53:02 of territory that you covered.

53:04 Uh,

53:05 and Dina's gonna respond to each and every point you made.

53:08 No,

53:08 uh,

53:09 Dina,

53:09 over to you.

53:10 Uh,

53:10 just after Dina's,

53:11 uh,

53:12 given her comments,

53:12 we're gonna open it up for Q&A in the room.

53:14 If you're online,

53:16 feel free to sort of raise your hand virtually or put a

53:19 comment or question in the chat and we'll manage,

53:22 um,

53:23 as we go forward.

53:24 So Dina,

53:24 over to you.

53:25 OK,

53:25 thank you,

53:26 um.

53:27 Intermit Dion Damian for the invitation to be part of this.

53:31 Um,

53:31 this was extremely,

53:32 uh,

53:32 thought provoking and,

53:34 um,

53:34 really a chance,

53:35 uh,

53:36 to reflect.

53:36 Um,

53:37 I should start by,

53:39 uh,

53:39 giving the caveat that I am not a health specialist.

53:42 Um,

53:43 so my perspectives come.

53:45 Um,

53:45 from my experience,

53:47 uh,

53:47 as HD regional director,

53:49 um,

53:50 during the pandemic,

53:51 uh,

53:52 covering West and Central Africa,

53:54 um,

53:54 where I learned a lot,

53:56 uh,

53:56 on the job,

53:57 um,

53:57 and then currently as HD,

53:59 uh,

54:00 director where,

54:01 you know,

54:01 I think we're still trying to come to grips with,

54:05 um,

54:06 uh,

54:06 what happened.

54:07 And so I think this kind of a conversation is,

54:10 um,

54:10 uh,

54:11 extremely helpful for,

54:12 for reflection.

54:13 Um,

54:14 and,

54:14 uh,

54:15 so,

54:16 let,

54:16 let me just start by saying that I think it's really

54:18 welcome that we're talking about the lessons from the pandemic.

54:22 I feel like this is a topic that no one,

54:24 Gabriel and I were discussing.

54:26 No one really wants to talk about anymore.

54:28 We,

54:28 I think we all.

54:29 All went through it and we want to move on,

54:31 um,

54:31 but I think that leaves us in,

54:33 you know,

54:33 the difficult place of,

54:35 uh,

54:35 panic and neglect,

54:37 uh,

54:38 conversations,

54:38 um,

54:39 and I've,

54:40 uh,

54:40 sorry,

54:40 I need to tell

54:41 whoever's trying to reach me that I'm not talking on the phone right now,

54:45 um,

54:45 so,

54:46 uh,

54:46 I,

54:46 I,

54:46 we're having these,

54:47 we're reenacting some of the panic and neglect conversations about

54:51 the need to invest in pandemic preparedness that we had.

54:54 Well,

54:54 before COVID,

54:55 um,

54:55 they're coming back.

54:56 So I think it's really important to remind ourselves why,

54:59 why this matters.

55:00 And,

55:00 you know,

55:01 I think it's really striking that,

55:03 um,

55:04 uh,

55:04 there was a,

55:05 uh,

55:06 uh,

55:06 work by CGD that suggests that there's,

55:09 um,

55:09 a 50/50 chance of another respiratory pandemic on the scale of COVID

55:14 during the next 25 years.

55:16 So we're all likely

55:17 to go through this again,

55:18 um,

55:19 which is terrifying.

55:20 I think it's also striking.

55:22 um,

55:22 the,

55:23 the mortality,

55:24 uh,

55:25 findings that you shared that,

55:26 um,

55:27 there's very little correlation between the

55:30 global health security index and preparedness and

55:33 how countries fared,

55:34 uh,

55:35 during the pandemic and that,

55:36 um,

55:37 really trust is key

55:39 and so I think in thinking about,

55:41 you know,

55:42 the so what and what do we do putting that front and center,

55:45 um,

55:45 is,

55:46 uh,

55:46 very important but also extremely challenging.

55:49 Um,

55:50 so just reflecting on my own experience,

55:52 I think these trade-offs that you're pointing to

55:55 between the need to invest in pandemic response and preparedness and

56:00 health systems and quality of care are real.

56:03 And when I was,

56:04 uh,

56:05 going through this in the Africa region,

56:06 I really saw firsthand how

56:08 countries struggled to respond to the immediate needs of the pandemic

56:12 and manage

56:13 weaknesses of,

56:15 uh,

56:15 health systems that,

56:16 that really were fragile or non-existent.

56:19 Um,

56:19 And you know,

56:20 I think there were two kinds of,

56:22 at least,

56:23 uh,

56:23 there were lots of different kinds of countries,

56:24 but two come to mind.

56:25 One is that,

56:26 you know,

56:27 there were countries that had existing healthcare systems,

56:30 primary healthcare,

56:32 um,

56:32 like Cabo Verde,

56:33 which was one of the countries that I got to visit during the pandemic.

56:36 They had,

56:36 I mean,

56:36 it's a very small island country,

56:38 uh,

56:38 well resourced in,

56:40 in,

56:40 in

56:41 some respects,

56:42 but they also had extremely strong.

56:44 Um,

56:44 primary care,

56:45 and they were able,

56:46 once they got access to the vaccine,

56:48 which is another story,

56:49 they were able to ramp up to,

56:51 you know,

56:51 far surpass OECD vaccination rates,

56:53 um,

56:54 really,

56:54 really quickly.

56:55 So having that

56:56 system in place mattered a lot.

56:58 The second was countries that were able to,

57:00 um,

57:01 use.

57:02 Uh,

57:02 the pandemic response to reinforce,

57:05 uh,

57:06 and,

57:06 and,

57:07 and,

57:07 and strengthen aspects of their systems,

57:10 even if they were weak and,

57:11 and really go through a learning process.

57:13 And the one that comes to mind was,

57:15 was

57:15 Cote d'Ivoire,

57:16 which was the first country that I visited,

57:18 um,

57:18 in November 21.

57:19 And,

57:20 um,

57:21 their

57:21 initial

57:22 vaccination response was really slow.

57:25 They had access to vaccines,

57:26 but they just couldn't get them out.

57:28 And so they did some thinking about why that was and started

57:31 to really get to the population.

57:33 So they had mobile

57:35 vaccination clinics,

57:37 um,

57:37 they,

57:38 uh,

57:38 expanded,

57:39 uh,

57:39 centers,

57:40 um,

57:41 in,

57:41 in communities,

57:42 and they were able to catch up,

57:43 um,

57:43 pretty quickly and be one of the countries that had a

57:46 Higher,

57:47 um,

57:47 uh,

57:47 rate of vaccination.

57:49 So,

57:49 I think,

57:49 you know,

57:50 these interactions that you point to between,

57:53 you know,

57:53 pandemic response and,

57:55 and,

57:55 and,

57:55 uh,

57:56 health systems and,

57:57 and health services are,

57:59 are really,

57:59 uh,

58:00 really important and,

58:01 and,

58:02 um,

58:02 you know,

58:03 I think the,

58:03 the tragedy in,

58:04 in,

58:05 in Africa was,

58:06 you know,

58:06 that for

58:08 quite a few countries,

58:09 the pandemic really put

58:10 health systems under strain

58:12 and this led to further gaps in,

58:15 you know,

58:15 basic immune.

58:16 ization

58:17 uh,

58:17 coverage,

58:18 non-COVID,

58:19 childhood vaccines,

58:20 and,

58:20 and other kinds of

58:22 drops in access to services.

58:24 Um,

58:25 so you talked about,

58:26 you know,

58:26 strong primary health care

58:28 as the foundation of

58:29 pandemic preparedness.

58:31 So,

58:31 so these things being linked now my colleagues in H&P and some of you

58:35 are here and I hope Tim and others will speak up during the.

58:37 Uh,

58:38 the conversation,

58:39 we call this resilient health systems,

58:41 really packaging

58:43 prevention and,

58:44 uh,

58:44 preparedness together with systems that are able to,

58:48 uh,

58:49 respond.

58:49 It's really this,

58:50 um,

58:51 this sweet spot of

58:53 win-wins that you pointed to in the case of,

58:56 um,

58:56 you,

58:56 you mentioned Thailand and,

58:57 and Vietnam.

58:59 So just thinking about,

59:00 you know,

59:00 what we can do to help countries

59:03 get to,

59:04 uh,

59:04 these win-wins and,

59:05 and build resilient,

59:06 uh,

59:07 health systems.

59:08 I think there's maybe 3 areas.

59:09 One is around financing and you have your headline,

59:12 it pays to invest in health.

59:14 I think that's great.

59:15 Um,

59:16 obviously the challenges are real in,

59:18 in lower income countries,

59:19 um.

59:20 Uh,

59:21 you know,

59:22 less than 2% of GDP is spent on health,

59:25 and

59:25 we know,

59:26 um,

59:26 because of work that colleagues have done that,

59:29 um,

59:29 because of the fiscal outlook in developing countries,

59:32 this is unlikely to,

59:34 uh,

59:35 increase,

59:35 uh,

59:36 uh,

59:36 between now and 2027.

59:38 Uh,

59:38 their projection is that health spending

59:40 is going to remain at about,

59:42 uh,

59:42 COVID or pre-COVID.

59:44 Levels

59:44 so fiscal space is really uh limited and so this is really uh

59:49 exercise in thinking about how countries can spend

59:52 um more if they can,

59:53 but more importantly how can they

59:56 um invest better and how can they think about some of these

59:59 trade offs and I,

1:00:01 I think you know that's the

1:00:03 um challenge that your

1:00:05 presentation gives us is,

1:00:06 you know,

1:00:07 given.

1:00:07 Uh,

1:00:08 the,

1:00:09 the needs and given the shifting burden of disease,

1:00:12 you know,

1:00:12 how do you prioritize,

1:00:14 um,

1:00:14 specific,

1:00:15 uh,

1:00:16 trade-offs in,

1:00:16 in health investments,

1:00:18 um,

1:00:19 which is,

1:00:19 I think the second area,

1:00:21 you know,

1:00:21 what are the investments that really add up to.

1:00:24 Uh,

1:00:24 resilient,

1:00:25 um,

1:00:25 uh,

1:00:26 systems that,

1:00:27 that respond to shifts in the burden of disease and also

1:00:30 increasing health emergencies and,

1:00:32 and,

1:00:33 you know,

1:00:33 we're talking about pandemics,

1:00:34 but I think,

1:00:35 um,

1:00:36 uh,

1:00:36 you know,

1:00:37 the climate

1:00:38 risks and,

1:00:39 and the,

1:00:40 um,

1:00:41 uh,

1:00:41 need for countries to build,

1:00:43 uh,

1:00:43 resilience to,

1:00:45 uh,

1:00:46 climate related health challenges are,

1:00:48 um,

1:00:48 uh,

1:00:49 just as,

1:00:49 as challenging.

1:00:50 So I think one element of this,

1:00:52 which I think it gets at this

1:00:55 point you made about the interaction between the population and health systems,

1:01:00 for me is around investing in,

1:01:01 um,

1:01:02 the health workforce and community health workers.

1:01:05 I think that's important not only for,

1:01:07 you know,

1:01:07 the kinds of services they can provide,

1:01:10 but it's community health workers who are also able,

1:01:13 um,

1:01:14 to,

1:01:14 uh,

1:01:15 contribute to trust.

1:01:17 And,

1:01:18 you know,

1:01:18 I think there's some.

1:01:19 Examples and anecdotes from,

1:01:21 from the pandemic,

1:01:22 um,

1:01:22 you know,

1:01:23 Nigeria,

1:01:23 for example,

1:01:24 was able to mobilize

1:01:26 50,000 community health workers who had been trained to deliver

1:01:30 polio vaccines to deliver COVID-19 vaccines.

1:01:34 So,

1:01:34 you know,

1:01:35 having these,

1:01:36 um,

1:01:37 people who can

1:01:38 be trained and retrained and sent out to communities,

1:01:41 um,

1:01:42 to deliver services,

1:01:43 um,

1:01:43 is,

1:01:44 is really.

1:01:44 Important.

1:01:45 And I think,

1:01:46 you know,

1:01:46 if you look at our health portfolio,

1:01:47 we're increasingly

1:01:49 working in this area and thinking through,

1:01:51 you know,

1:01:52 the,

1:01:52 uh,

1:01:52 the supply side incentives for providers and the

1:01:55 issues around,

1:01:56 um,

1:01:56 you know,

1:01:57 behaviors of providers and,

1:01:58 and,

1:01:58 and incentives and quality,

1:02:00 but I think this is an area where,

1:02:02 you know,

1:02:02 we,

1:02:02 we need to think together about what,

1:02:04 what really

1:02:05 works.

1:02:05 Um,

1:02:06 I think it going continuing on this idea of trust,

1:02:09 I think some of the.

1:02:10 Work of the embed

1:02:11 unit and thinking about behavioral,

1:02:13 uh,

1:02:14 uh,

1:02:15 interventions.

1:02:16 Um,

1:02:16 we saw some thinking about this during the pandemic and,

1:02:20 you know,

1:02:20 what

1:02:21 nudges and messaging and,

1:02:22 and engagement with,

1:02:24 um,

1:02:24 people in communities leads to,

1:02:26 um,

1:02:27 uh,

1:02:27 less hesitancy around vaccines and more take up.

1:02:30 I think there's a lot there to,

1:02:32 to think about,

1:02:33 especially at this intersection.

1:02:35 That you talked about.

1:02:36 Um,

1:02:37 the other is,

1:02:38 uh,

1:02:39 what technology can do and,

1:02:41 and the role of,

1:02:42 um,

1:02:43 dig digital and,

1:02:44 and AI and health,

1:02:46 um.

1:02:46 One of the examples in the collapse and recovery,

1:02:49 uh,

1:02:50 report that that Norbert and colleagues did on the impact of the pandemic,

1:02:54 one of the examples there is in Pakistan where,

1:02:56 um,

1:02:56 in the first year of the pandemic,

1:02:58 uh,

1:02:59 uh,

1:02:59 over a million kids were,

1:03:00 um,

1:03:01 left unvaccinated,

1:03:03 but they were able to use an electronic registry

1:03:05 of immunization to find kids and vaccinate them,

1:03:08 and they caught up pretty quickly.

1:03:10 So,

1:03:10 you know,

1:03:10 what are these instruments that can.

1:03:12 Um,

1:03:13 leverage technology to,

1:03:15 um,

1:03:15 uh,

1:03:16 to,

1:03:17 to help,

1:03:17 um,

1:03:18 health systems be more,

1:03:20 uh,

1:03:20 uh,

1:03:21 agile and,

1:03:21 and,

1:03:22 and resilient,

1:03:23 um,

1:03:24 and then I think the third,

1:03:25 uh,

1:03:25 area is around,

1:03:27 uh,

1:03:27 increasing equitable access to,

1:03:30 you know,

1:03:30 the kinds of medical countermeasures like vaccines that you talked about,

1:03:34 and I think there's a lot of

1:03:36 lessons and I'll watch Tristan's,

1:03:38 um.

1:03:39 Uh,

1:03:40 talk that you link in,

1:03:41 in your report because I missed that.

1:03:43 But,

1:03:43 you know,

1:03:43 I think

1:03:45 I completely agree that the rollout of vaccines was a game changer,

1:03:48 but in our countries,

1:03:50 it was,

1:03:50 it was a real struggle,

1:03:52 right?

1:03:52 So,

1:03:53 um,

1:03:53 you know,

1:03:53 45% of Americans got access to one dose of the vaccine before 1% of Ethiopians did,

1:04:00 right?

1:04:00 So,

1:04:00 and that's just,

1:04:01 you know,

1:04:01 one number.

1:04:03 It was really striking how,

1:04:05 um,

1:04:06 uh,

1:04:06 African countries and developing countries at large really lagged behind and

1:04:11 we were able to respond through things like,

1:04:13 you know,

1:04:14 the innovative partnership that we had with

1:04:15 the African Union under the AVAT arrangements and

1:04:19 the bank was able to,

1:04:20 you know,

1:04:20 help countries,

1:04:21 um.

1:04:22 Uh,

1:04:22 get access,

1:04:23 um,

1:04:24 uh,

1:04:24 he,

1:04:25 he just,

1:04:25 uh,

1:04:26 retired,

1:04:26 but,

1:04:26 um,

1:04:27 uh,

1:04:27 Enzo,

1:04:28 you know,

1:04:28 our chief procurement officer was just,

1:04:30 uh,

1:04:31 incredible at helping countries,

1:04:33 you know,

1:04:34 connect with pharmaceutical companies to get contracts and,

1:04:37 and all of this,

1:04:38 um,

1:04:39 was,

1:04:39 was very important.

1:04:40 But as we think forward and,

1:04:42 and think about how the bank can do better next time.

1:04:45 I think,

1:04:45 you know,

1:04:46 questions around should we be,

1:04:47 uh,

1:04:48 together with IFC,

1:04:49 um,

1:04:50 helping countries build manufacturing capacity so they can more quickly,

1:04:54 uh,

1:04:54 get access to vaccine.

1:04:56 What kind of at-risk financing mechanisms are there so that the bank can

1:05:00 help countries,

1:05:01 um,

1:05:02 Uh,

1:05:02 compete

1:05:03 on a level playing field in the market next time they need to get,

1:05:06 um,

1:05:07 uh,

1:05:07 vaccines,

1:05:08 uh,

1:05:08 and so on.

1:05:09 So,

1:05:10 um,

1:05:10 I think this is,

1:05:11 these,

1:05:11 some of these ideas are,

1:05:12 you know,

1:05:13 that I

1:05:13 threw out in the area of what makes a

1:05:16 resilient health system are very much embedded in the,

1:05:19 um,

1:05:19 health emergency preparedness

1:05:21 global challenge.

1:05:22 Program,

1:05:22 which you may have heard about.

1:05:23 And

1:05:24 I think you,

1:05:25 you know,

1:05:25 we're already working with DEC on

1:05:27 some elements of that around impact evaluation

1:05:30 and what kind of a monitoring framework,

1:05:31 and I really think we need,

1:05:33 um,

1:05:34 to continue that.

1:05:35 There are sort of three areas that are envisaged under that,

1:05:37 um,

1:05:38 global challenge program,

1:05:39 which,

1:05:39 you know,

1:05:40 are going to be made available to,

1:05:41 to all countries,

1:05:42 um.

1:05:43 The first one's around core public health,

1:05:45 uh,

1:05:46 services and systems,

1:05:47 and I think,

1:05:48 you know,

1:05:48 there's a very blurry line,

1:05:50 as you pointed to between what's primary health care and,

1:05:53 and

1:05:54 what's essential and what's

1:05:56 around preparedness.

1:05:57 I think they're,

1:05:57 you know,

1:05:58 they really go together.

1:05:59 The second is around access to financing and the third is.

1:06:02 Around,

1:06:02 um,

1:06:03 you know,

1:06:03 what are the,

1:06:04 the tools,

1:06:04 the,

1:06:05 the,

1:06:05 the countermeasures,

1:06:06 the vaccines,

1:06:07 diagnostics,

1:06:08 um,

1:06:08 and others,

1:06:09 uh,

1:06:09 things that countries need to be able to be prepared,

1:06:12 uh,

1:06:12 for any kind of health emergency.

1:06:14 So,

1:06:15 um,

1:06:16 we're

1:06:16 joined at the hip,

1:06:17 I guess,

1:06:17 on this,

1:06:18 and,

1:06:18 um,

1:06:19 thanks so much for inviting me.

1:06:23 Thank you,

1:06:23 Dina.

1:06:26 And,

1:06:26 and,

1:06:26 and thanks for bringing up the Global Challenge Program because in

1:06:29 fact this is the first of what I hope is uh several

1:06:33 PRT's policy research talks that we do that are actually linked

1:06:37 to the GCP.

1:06:38 So I don't know if you,

1:06:39 it was subtly in the title that this was a global challenges research insights talk

1:06:43 and we hope to have a few more of them actually on,

1:06:44 on,

1:06:45 on all of the GCPs.

1:06:46 Um,

1:06:47 so let's open it up.

1:06:48 I see intermit you've unmuted yourself,

1:06:50 so I presume that means you're chomping at the bit for a question.

1:06:54 Um,

1:06:55 I have a question,

1:06:55 but I can wait for the others.

1:06:57 The others are actually,

1:06:58 um,

1:06:58 yeah.

1:06:59 Well,

1:06:59 when you start,

1:07:01 are there any questions in the room if you want to

1:07:02 just raise your hand so that I have a sense of

1:07:05 Uh,

1:07:05 OK,

1:07:06 there's a couple in the room.

1:07:07 So in a minute,

1:07:07 why don't we start with you,

1:07:08 we'll do a few more in the room and then please,

1:07:10 if you're online,

1:07:11 please

1:07:11 raise your virtual hand or,

1:07:13 or let me know in the chat that you,

1:07:14 you,

1:07:15 you,

1:07:15 you have a question.

1:07:16 So in a minute,

1:07:17 you,

1:07:17 you,

1:07:17 you kick us off.

1:07:20 So,

1:07:20 you know,

1:07:20 um,

1:07:21 um,

1:07:23 So I'm going back to the point

1:07:25 that I see

1:07:27 in Damien's PowerPoint,

1:07:29 which was the,

1:07:29 that Thailand and Vietnam had strong primary care systems.

1:07:34 So I was thinking,

1:07:35 OK,

1:07:36 strong,

1:07:36 let's say that strong means strong has a quantity aspect to it,

1:07:40 and strong has a quality aspect to it.

1:07:43 So my question um

1:07:45 to him was,

1:07:46 like,

1:07:47 you know,

1:07:48 say that you have,

1:07:49 uh,

1:07:50 or

1:07:51 during a pandemic,

1:07:52 relative to normal times,

1:07:55 does quality of care matter more

1:07:58 than the quantity?

1:08:02 Because then

1:08:03 I guess if the answer to that is yes,

1:08:05 Damien,

1:08:06 then one of the best ways to prepare

1:08:09 for a pandemic

1:08:10 is to continue to invest in primary healthcare.

1:08:14 Rather than something,

1:08:16 uh,

1:08:17 you,

1:08:17 you know,

1:08:18 uh,

1:08:18 something which is specific to,

1:08:20 uh,

1:08:21 specific to a pandemic.

1:08:23 But invest more in the quality part,

1:08:26 as compared with a situation where you're not expecting to have pandemics,

1:08:30 for example.

1:08:31 Stop that.

1:08:33 OK,

1:08:34 thanks.

1:08:34 I probably usually we actually turn it back

1:08:36 to the speaker right after the the discussion.

1:08:38 I'm sorry.

1:08:38 So we'll we'll incorporate

1:08:40 any responses to DNA in this round if you if you don't mind.

1:08:43 Apologies for that.

1:08:44 Tim.

1:08:45 Uh,

1:08:45 and then Jed and then Gel.

1:08:47 Sure,

1:08:48 uh,

1:08:48 thanks,

1:08:48 Demia,

1:08:49 and,

1:08:49 and glad that,

1:08:50 uh,

1:08:50 you're not talking about

1:08:52 death and sex,

1:08:52 you're talking about,

1:08:53 uh,

1:08:53 death and taxes,

1:08:54 so you've got,

1:08:55 got an additional aspect there.

1:08:57 Um,

1:08:58 so yeah,

1:08:59 uh,

1:08:59 we worked together in the early 8

1:09:01 things in Brooking and elsewhere,

1:09:02 so it's great to hear your perspectives,

1:09:04 um,

1:09:05 maybe an observation and,

1:09:06 and perhaps a question,

1:09:07 um.

1:09:08 I,

1:09:08 you know,

1:09:09 great to be bringing evidence on this.

1:09:10 I think there's a challenge both in messaging and even in these GCPs

1:09:14 on how to frame this kind of

1:09:16 interaction between pandemic preparedness and health systems

1:09:19 and in a sense it's a,

1:09:20 it's a more complicated challenge.

1:09:22 It's more difficult than health and say education.

1:09:24 We just talk about learning losses and skills

1:09:27 because in health we say,

1:09:27 well,

1:09:28 there's pandemic preparedness and there's health system strengthening

1:09:30 and there's primary care and there's climate resilience

1:09:32 and I,

1:09:33 I think sometimes the,

1:09:34 the messaging gets.

1:09:35 You know,

1:09:36 and that distinction is,

1:09:37 is challenging,

1:09:38 and,

1:09:38 and I think it's non-trivial because as we move into this GCP,

1:09:42 you know,

1:09:42 global challenge program,

1:09:43 there will be those thinking

1:09:45 if I'm doing a global challenge program focused on,

1:09:48 you know,

1:09:48 as a country director says as long as I'm doing

1:09:50 pandemic preparedness and strengthening my laboratory and other systems,

1:09:53 then.

1:09:54 I'm good

1:09:55 and the health specialists will say no,

1:09:57 you need to be looking at the systems

1:09:59 um

1:10:00 and so I,

1:10:01 I think there's a messaging issue but there's an evidence issue and I'm wondering,

1:10:04 do you,

1:10:04 do you have anything coming out of the,

1:10:07 is there more we can say on the evidence side about the relative balance

1:10:11 or

1:10:11 the importance in terms of the type of pandemic,

1:10:14 you know,

1:10:14 including as you move from a focused pandemic,

1:10:17 you know,

1:10:17 outbreak like.

1:10:18 Uh,

1:10:19 Ebola or,

1:10:20 you know,

1:10:21 SARS,

1:10:21 where,

1:10:21 you know,

1:10:22 rapid response and control

1:10:24 to where you're in a much more generalized situation

1:10:27 where,

1:10:27 you know,

1:10:28 it's no longer about border control,

1:10:29 but it's about the entire health system's response.

1:10:31 Um,

1:10:32 I mean,

1:10:32 do we have any insights there's a way that we can

1:10:35 bring in the evidence to think about that,

1:10:37 um,

1:10:38 and then I think there is a challenge on,

1:10:40 on the overall messaging,

1:10:41 um,

1:10:42 other topics would be interesting to,

1:10:43 to discuss,

1:10:44 but I think that's,

1:10:45 that's something I'm kind of,

1:10:46 you know,

1:10:47 wrestling with a little bit.

1:10:48 Thanks.

1:10:52 Great,

1:10:52 uh,

1:10:54 OK.

1:10:54 Uh,

1:10:55 thanks Damian for the great talk and Dina for the

1:10:57 fantastic comments.

1:10:58 Um.

1:10:59 Just uh another thought to throw into the mix that's already been

1:11:03 started by Intermitt and and Tim.

1:11:05 Um

1:11:07 And I of course don't want to take away from the

1:11:09 usefulness of investing in health systems because as you're arguing,

1:11:13 investing in pandemic preparedness are in many ways is a general investment or

1:11:16 can be seen as general investment in health systems with many returns.

1:11:20 Uh,

1:11:20 but from the pandemic

1:11:21 averting or,

1:11:23 or,

1:11:23 uh,

1:11:24 minimizing perspective,

1:11:25 you did mention briefly the importance of the human-animal

1:11:29 interface,

1:11:31 uh,

1:11:31 either with wild animals or with domestic animals.

1:11:34 And I guess

1:11:35 the layman,

1:11:37 the layperson in me

1:11:38 would think,

1:11:39 well,

1:11:39 that could be a very efficient use of funds to try to minimize

1:11:43 contacts there since most likely

1:11:45 the next pandemic will come from a,

1:11:47 from a,

1:11:48 you know,

1:11:48 zoonotic origin.

1:11:49 So,

1:11:50 I,

1:11:50 I'm not familiar,

1:11:51 but can you speak a bit about the relative

1:11:53 cost effectiveness of investments in that domain as well?

1:11:57 Thanks.

1:11:59 Thanks,

1:11:59 Chad.

1:11:59 Let's go to Gabriel and then we'll turn it back

1:12:01 to Damien and then we'll open up for another round.

1:12:04 So please

1:12:06 think of your questions.

1:12:07 Yeah,

1:12:08 yeah,

1:12:08 so just,

1:12:09 um,

1:12:09 I think echoing kind of every,

1:12:11 everybody else and in particular,

1:12:13 Dina,

1:12:13 I mean,

1:12:13 on this sort of general point that I think it's,

1:12:16 you know,

1:12:16 it's quite frustrating that the pandemic is so much in

1:12:18 the rearview mirror now and we just haven't been doing this

1:12:22 sort of

1:12:22 analysis of

1:12:24 what happened,

1:12:24 what do we do right,

1:12:25 and,

1:12:25 and what can we do

1:12:27 better

1:12:27 next time.

1:12:28 I think that covers

1:12:29 a whole lot of ground including on the,

1:12:31 the health response

1:12:32 and just on this question,

1:12:34 I mean,

1:12:34 I,

1:12:34 I,

1:12:34 I definitely.

1:12:36 I want to believe the basic idea that investing in

1:12:39 the health system is going to help with pandemic preparedness,

1:12:42 uh,

1:12:43 but I'm skeptical of that.

1:12:44 I mean,

1:12:44 since we're among friends,

1:12:45 I think I can,

1:12:46 uh,

1:12:47 express my skepticism on the general point.

1:12:49 I mean,

1:12:49 I,

1:12:49 and I,

1:12:50 we look,

1:12:50 I know we all look at the pandemic in terms of our own personal experience and,

1:12:53 uh,

1:12:53 uh,

1:12:54 with the bank,

1:12:54 so I was in Manila,

1:12:56 uh,

1:12:56 at the beginning of HTPL.

1:12:58 So January 2020,

1:12:59 we're all kind of looking around to say,

1:13:01 OK,

1:13:01 how do we evaluate this,

1:13:02 how do we evaluate

1:13:03 how well our countries are prepared,

1:13:05 and the,

1:13:05 the go to reference was the Global Health Security index.

1:13:09 So we're,

1:13:09 we were going country by country and saying,

1:13:11 OK,

1:13:11 the Thailand looks pretty good,

1:13:13 Malaysia looks pretty good,

1:13:14 Philippines,

1:13:15 not,

1:13:15 not so clear.

1:13:16 And then,

1:13:17 you know,

1:13:18 maybe six months later,

1:13:20 uh,

1:13:21 or later in 2020,

1:13:22 you know,

1:13:22 I looked at.

1:13:23 The correlation between the GHSI

1:13:26 and

1:13:27 outcomes and that was

1:13:28 0

1:13:29 and that's,

1:13:29 and there's now a bunch of papers which show the same thing and as you pointed out,

1:13:32 the one thing which really comes clearly through in any kind of cross-country

1:13:36 analysis is that a trust measure so countries that have

1:13:39 higher measures of trust that did,

1:13:41 did better,

1:13:42 but nothing in the GSHSI which is sort of a bunch of measures of basic healthcare

1:13:47 quality and,

1:13:48 and quantity.

1:13:49 And then when I was in Colombia a couple of years later,

1:13:52 the team did a pandemic preparedness report looking

1:13:56 at all the questions of pandemic preparedness for Colombia,

1:13:59 and their set of recommendations was basically

1:14:02 improve the healthcare system in many,

1:14:05 many different ways.

1:14:06 And so I sort of put those two things together,

1:14:07 you know,

1:14:08 my,

1:14:08 my feeling was,

1:14:09 well,

1:14:09 how,

1:14:09 how do we know these things are actually gonna help for pandemic,

1:14:12 uh,

1:14:12 preparedness,

1:14:13 and I still,

1:14:13 that's still the question that,

1:14:14 that I have.

1:14:15 And I also worry a little bit.

1:14:17 That

1:14:18 selling that health system's investment story

1:14:21 is going to cause us to neglect other things

1:14:23 that we could do in terms of pandemic preparedness

1:14:26 where we do have a little bit more

1:14:27 evidence.

1:14:28 I mean,

1:14:28 11 thing,

1:14:29 for example,

1:14:29 is

1:14:30 wastewater,

1:14:31 uh,

1:14:32 monitor surveillance.

1:14:33 I,

1:14:33 I think the evidence is pretty clear that

1:14:35 that's low cost,

1:14:37 high,

1:14:37 high benefit,

1:14:38 you know,

1:14:39 also a benefit not just during the pandemic but also

1:14:42 for understanding general

1:14:44 disease trajectory at other times.

1:14:46 So,

1:14:47 so,

1:14:47 I just want to share my

1:14:49 skepticism on that,

1:14:51 on that major uh point.

1:14:56 Thanks,

1:14:56 back to you,

1:14:56 Damien.

1:15:00 Yeah,

1:15:01 uh,

1:15:01 thanks a lot for the

1:15:02 comments,

1:15:03 questions.

1:15:03 It's a lot to cover and to answer I.

1:15:06 Apologies if I,

1:15:08 if I don't

1:15:09 do it,

1:15:09 uh,

1:15:10 fully,

1:15:11 so,

1:15:11 uh,

1:15:13 then uh some,

1:15:13 some

1:15:14 quick,

1:15:15 uh,

1:15:15 response,

1:15:16 uh.

1:15:17 So on the yes I mean there is the the issue of financing in the fiscal space and

1:15:22 maybe we had some some uh increase

1:15:25 of that fiscal space during COVID and now we are back to

1:15:29 before that's a little bit this

1:15:30 panic and neglect cycle,

1:15:32 um,

1:15:34 one point is that

1:15:35 for example the

1:15:37 so-called sin taxes that

1:15:39 I advocated

1:15:40 are a way to increase the.

1:15:41 The fiscal space.

1:15:42 I mean,

1:15:42 in some countries where

1:15:44 not many people are smoking or not people like in Africa

1:15:47 or not people,

1:15:48 many people are

1:15:49 drinking

1:15:51 soda,

1:15:52 that might not bring a lot of money,

1:15:53 but that's

1:15:54 that's one way

1:15:55 where it's a win-win.

1:15:56 You increase the fiscal space.

1:15:58 Um,

1:15:59 and you,

1:16:00 uh,

1:16:00 and you reduce,

1:16:02 uh,

1:16:02 unhealthy,

1:16:03 uh,

1:16:03 behavior.

1:16:04 Uh,

1:16:05 the community health workers,

1:16:06 I,

1:16:06 I fully agree that's something I

1:16:09 wanted to cover and

1:16:10 Don told me you're already covering,

1:16:11 uh,

1:16:12 a lot,

1:16:13 but I think that,

1:16:14 I mean,

1:16:14 that there's a lot of evidence,

1:16:16 especially when

1:16:17 we don't have enough,

1:16:18 uh,

1:16:18 doctors and nurse that,

1:16:20 uh,

1:16:21 we could do a lot more with community health workers.

1:16:24 There is an important issue.

1:16:26 Uh,

1:16:26 is that

1:16:27 is are you compensate them,

1:16:29 and I know we have the issue of the,

1:16:31 but,

1:16:32 but most of the.

1:16:34 Successful experiment with community health workers have been like

1:16:38 from

1:16:39 um

1:16:40 special interventions from donors where they were well compensated

1:16:44 and there is

1:16:45 less evidence that

1:16:47 if they are not

1:16:48 paid

1:16:49 a regular amount of money,

1:16:50 not necessarily a salary,

1:16:52 it's difficult and,

1:16:53 and,

1:16:53 and we know that

1:16:54 uh

1:16:55 health ministries are very reluctant to put more people on their

1:16:59 payroll so that that's a question that needs to be addressed,

1:17:02 um.

1:17:04 Intermit the quality versus quantity during the pandemic,

1:17:08 I think it was a

1:17:09 combination of both.

1:17:10 I mean,

1:17:11 it's,

1:17:11 it was clearly

1:17:13 at some point just quantity.

1:17:15 Uh,

1:17:15 we needed the number of vaccines at some point early on we needed the

1:17:18 number of beds,

1:17:19 but we know

1:17:20 we also,

1:17:21 um,

1:17:22 needed

1:17:23 the,

1:17:24 for example,

1:17:25 there,

1:17:25 uh,

1:17:26 when I was talking about equipment we know that even if we had beds we needed oxygen,

1:17:31 so

1:17:32 um.

1:17:33 That's,

1:17:33 uh,

1:17:34 so it's a combination of both,

1:17:36 but I as

1:17:39 So

1:17:39 a lot of discussion have been about,

1:17:41 you know,

1:17:42 um.

1:17:44 No,

1:17:44 I should clarify my question.

1:17:47 OK,

1:17:47 to clarify my question,

1:17:48 Jamie.

1:17:51 The

1:17:53 Uh,

1:17:53 you,

1:17:53 you said that trust becomes a more important thing during a pandemic.

1:17:57 And somewhere along the way,

1:17:58 you also said that trust and quality

1:18:02 are more highly correlated than trust and quantity.

1:18:06 So that's why I was thinking

1:18:07 that why aren't you connecting them and saying,

1:18:10 well,

1:18:10 a good way to prepare for pandemics

1:18:12 is,

1:18:13 of course,

1:18:13 to increase the trust in the system,

1:18:15 and the shorter cut to that is to increase the quality,

1:18:18 because,

1:18:19 you know,

1:18:19 I could imagine somebody who,

1:18:21 who does not have

1:18:23 easy access to the system,

1:18:25 uh,

1:18:26 during normal times,

1:18:28 might actually make an effort to actually access it.

1:18:31 Uh,

1:18:32 during a pandemic,

1:18:34 but they won't make,

1:18:35 but they won't make that effort if they didn't trust the system.

1:18:50 Trust

1:18:51 is we

1:18:52 we can't hear you

1:18:54 sorry,

1:18:55 sorry,

1:18:55 let me repeat

1:18:56 independently of trust,

1:18:58 investing in quality of health care is already important just

1:19:01 given the number I've I've given from that that paper

1:19:05 by Margaret Krookk and others

1:19:07 then I think you're right.

1:19:08 I mean investing in quality is the way to build

1:19:11 trust,

1:19:12 um.

1:19:14 In the sense that,

1:19:16 and I,

1:19:16 I think also

1:19:18 for example we are working with Aditya in

1:19:21 in in East Asia on a report on the

1:19:24 primacy of primary care.

1:19:27 So basically

1:19:28 the way you develop trust

1:19:30 in a health system is

1:19:32 having access to a regular primary care provider.

1:19:36 You establish

1:19:37 a relationship,

1:19:38 you trust that person and then.

1:19:40 When that

1:19:41 person tells you,

1:19:42 well,

1:19:42 you should wear a mask or you should

1:19:44 come and get vaccinated,

1:19:46 you should come

1:19:47 and

1:19:49 you are 35 or 40,

1:19:50 you should come for screening for diabetes or

1:19:54 hypertension,

1:19:56 the

1:19:57 population are more likely to trust them.

1:20:00 Um,

1:20:03 So the

1:20:06 Team,

1:20:06 the so this interaction between uh

1:20:09 pandemic preparedness and

1:20:12 quality or strong health systems,

1:20:15 uh,

1:20:16 yeah,

1:20:16 I think we should

1:20:17 avoid that dichotomy.

1:20:18 I,

1:20:18 I see it coming around,

1:20:21 uh,

1:20:21 so it's I mean I,

1:20:22 I think.

1:20:24 Jet and Gabrielle,

1:20:25 well,

1:20:26 Gabriel is more skeptical,

1:20:27 so.

1:20:28 Um,

1:20:30 I,

1:20:30 I,

1:20:31 I believe,

1:20:31 I mean,

1:20:32 I don't have a strong evidence.

1:20:33 I,

1:20:33 I provided evidence from,

1:20:35 uh,

1:20:36 that paper by Arseno and other,

1:20:39 uh.

1:20:40 COVID-19 vaccination rates were

1:20:42 positively correlated with

1:20:45 having a regular primary uh physician

1:20:47 with trusting the health system,

1:20:50 so

1:20:51 I,

1:20:51 I do believe that uh.

1:20:54 That works

1:20:55 hand in hand,

1:20:56 uh,

1:20:56 trust and quality and

1:20:58 pandemic preparedness.

1:20:59 I agree that we need,

1:21:01 uh,

1:21:01 other things,

1:21:02 for example,

1:21:02 one health.

1:21:03 I'm not a specialist,

1:21:05 but,

1:21:05 uh,

1:21:06 so I,

1:21:06 I don't know

1:21:08 the cost,

1:21:08 cost effectiveness.

1:21:09 Uh,

1:21:09 I'm,

1:21:10 I'm sorry,

1:21:10 it seems that it could be also very cost effective.

1:21:14 Also,

1:21:15 I don't know how costly it is,

1:21:16 for example,

1:21:17 to

1:21:18 uh

1:21:19 acceptable it would be to cut every wet market in Asia.

1:21:24 Uh,

1:21:24 and

1:21:25 I,

1:21:25 I don't know how feasible it is,

1:21:27 but

1:21:27 um.

1:21:29 But clearly in terms of surveillance,

1:21:31 it should be feasible,

1:21:32 including

1:21:33 wastewater

1:21:35 surveillance.

1:21:36 So I,

1:21:37 I guess I've

1:21:38 touched a little bit each of your points,

1:21:40 but not all of them.

1:21:43 So we have a

1:21:44 couple more minutes um.

1:21:48 I want to give people online a chance.

1:21:49 I,

1:21:50 I think somebody raised their hand and then put it back down,

1:21:52 but since we have a minute,

1:21:53 if you have a,

1:21:54 you know,

1:21:54 a 32nd question,

1:21:56 now's a good time.

1:21:58 Otherwise,

1:21:58 I do wanna ask Dina if she has any rejoinders to any of the questions or comments.

1:22:04 Uh,

1:22:05 do you wanna,

1:22:06 do you have,

1:22:06 OK,

1:22:07 Dina.

1:22:09 No,

1:22:09 I mean,

1:22:09 look,

1:22:10 I think that this is asking the all the right questions,

1:22:13 right,

1:22:13 about,

1:22:14 um,

1:22:14 you know,

1:22:15 how to prioritize and,

1:22:17 and phase,

1:22:18 uh,

1:22:18 investments and,

1:22:19 you know,

1:22:19 throwing in one health is absolutely relevant and

1:22:22 it's a big,

1:22:23 uh,

1:22:23 piece of the,

1:22:24 um,

1:22:25 work,

1:22:26 uh,

1:22:26 that's gone into the,

1:22:27 um,

1:22:28 the GCP with together with,

1:22:30 uh,

1:22:30 our ag colleagues,

1:22:31 um,

1:22:31 but we need,

1:22:32 uh,

1:22:33 to look at these questions of,

1:22:35 uh,

1:22:35 trade-offs and,

1:22:36 and,

1:22:36 and cost effectiveness and.

1:22:38 I fully agree with Tim that this,

1:22:40 you know,

1:22:41 framing is really important and I see it tripping us up even in the

1:22:46 conversations,

1:22:46 uh,

1:22:47 internally,

1:22:48 um,

1:22:48 uh,

1:22:49 you know,

1:22:49 are we putting,

1:22:50 uh,

1:22:50 I mean,

1:22:51 I,

1:22:51 I heard it,

1:22:52 you know,

1:22:52 from,

1:22:52 from,

1:22:53 uh,

1:22:55 uh,

1:22:56 important people in the institution.

1:22:57 Are we,

1:22:58 you know,

1:22:58 um,

1:22:59 uh,

1:22:59 throwing our exit preparedness at the expense of,

1:23:02 um.

1:23:03 Uh,

1:23:04 health system strengthening,

1:23:05 UHC primary care,

1:23:06 and I think we need to be able to map,

1:23:09 you know,

1:23:09 how these things reinforce each other and,

1:23:12 um,

1:23:12 you know,

1:23:13 have some sort of a.

1:23:16 Uh,

1:23:16 a framework for,

1:23:18 you know,

1:23:18 prioritizing within,

1:23:20 you know,

1:23:21 uh,

1:23:22 this,

1:23:22 these two subsets that are really overlapping interventions.

1:23:26 Um,

1:23:26 so,

1:23:27 I,

1:23:27 I think you're asking the right questions and,

1:23:29 and we need

1:23:30 also,

1:23:31 you know,

1:23:31 uh,

1:23:31 you rightly,

1:23:32 uh,

1:23:32 put it also in the context of the shifting burden of disease,

1:23:36 right?

1:23:36 And,

1:23:36 uh,

1:23:37 and,

1:23:37 and,

1:23:37 and we have

1:23:38 a lot of different patterns going across,

1:23:41 right?

1:23:41 The,

1:23:42 um,

1:23:42 Uh,

1:23:43 the,

1:23:43 the,

1:23:44 the regions and,

1:23:45 and countries.

1:23:45 So thanks for,

1:23:46 uh,

1:23:47 throwing these ideas out,

1:23:49 and I,

1:23:49 I think we need to,

1:23:50 you know,

1:23:51 follow up and,

1:23:51 and,

1:23:52 and sort of

1:23:55 decompose some of these,

1:23:56 uh,

1:23:56 these questions,

1:23:57 uh,

1:23:58 further.

1:23:58 Thanks.

1:23:59 Thanks,

1:23:59 Dina.

1:24:00 Um,

1:24:00 in a minute,

1:24:00 I'll turn it over to you in one second,

1:24:02 but just let me,

1:24:02 in conclusion,

1:24:03 from my perspective,

1:24:04 say I,

1:24:05 I really,

1:24:06 this has been incredibly insightful,

1:24:08 but also I've really enjoyed the sort of the research operations

1:24:13 joint discussion that we've had in this session,

1:24:15 you know,

1:24:15 bringing together kind of

1:24:17 all this evidence and research and then

1:24:20 Both your experience but other people's experience in the room actually

1:24:24 literally going

1:24:26 going through the operational side during the pandemic but

1:24:28 also sort of reflecting on it together afterwards.

1:24:31 So

1:24:31 I really thought that was

1:24:33 great and and

1:24:35 You know,

1:24:35 as we think about the,

1:24:36 the,

1:24:37 the Global Challenge program,

1:24:39 I think

1:24:40 jointly thinking about how to sort of shape that

1:24:43 and what that's gonna involve both on the operational,

1:24:45 but as well as the knowledge agenda that's associated with that,

1:24:49 I think this is the start of that conversation and certainly not the end.

1:24:52 But,

1:24:53 but in a minute,

1:24:53 over to you to,

1:24:54 to wrap us up.

1:24:56 Uh,

1:24:56 thanks everybody.

1:24:58 Yeah,

1:24:59 thank you,

1:24:59 uh,

1:25:00 Dion.

1:25:00 Uh,

1:25:00 I,

1:25:01 so,

1:25:01 so I wanted to go back to the the point that I started with,

1:25:05 which was,

1:25:05 you know,

1:25:06 to try to sort of see whether or not

1:25:08 during the pandemic,

1:25:10 did we

1:25:11 kind of get herded

1:25:13 into

1:25:14 saying the same things

1:25:16 for all countries.

1:25:17 And those things were basically the things

1:25:20 that we were hearing.

1:25:22 Um,

1:25:23 the,

1:25:23 the medical practitioners,

1:25:25 as well as

1:25:26 the public health officials and others,

1:25:28 say for advanced economies,

1:25:30 right?

1:25:31 Uh,

1:25:31 so,

1:25:31 I thought

1:25:32 that's an important question for Dina,

1:25:35 because,

1:25:35 uh,

1:25:37 so as strategy for the next time around,

1:25:39 I think it,

1:25:40 it would be really important to actually see

1:25:42 whether we would,

1:25:43 um,

1:25:44 do the same thing that we did the last time or not.

1:25:47 That was one thing.

1:25:48 The second thing,

1:25:49 and,

1:25:49 uh,

1:25:50 uh,

1:25:50 the,

1:25:51 there,

1:25:51 I thought it was very important to sort of look at these data

1:25:55 that Damien presented,

1:25:56 and

1:25:57 he sort of showed,

1:25:59 uh,

1:26:00 he,

1:26:00 he,

1:26:00 he,

1:26:01 he showed the excess mortality numbers being quite different,

1:26:04 for example,

1:26:05 especially for lack and ECCA.

1:26:08 And that kind of surprised me because I would have thought that,

1:26:11 I would have thought that those,

1:26:13 those,

1:26:14 uh,

1:26:15 those were the two regions where the quality,

1:26:17 at least,

1:26:18 of the healthcare systems would have been better as compared to the others,

1:26:21 but maybe I'm missing something.

1:26:23 The point that,

1:26:24 that I'm trying to sort of make is that,

1:26:26 would there be region-specific uh

1:26:29 pandemic strategies?

1:26:31 So rather than think about this

1:26:33 in a very global way,

1:26:35 would it help

1:26:36 us if we sort of thought about it

1:26:38 for a subset of countries?

1:26:40 And I think that,

1:26:40 that,

1:26:41 that you,

1:26:41 you,

1:26:41 you,

1:26:41 you,

1:26:42 you could sort of think about it as

1:26:44 um

1:26:45 Uh,

1:26:46 by region,

1:26:47 because

1:26:48 that's a good proxy

1:26:49 for quality or some other indicators of primary,

1:26:53 secondary,

1:26:53 tertiary healthcare.

1:26:55 Or you could think about a better categorization of saying that,

1:26:58 OK,

1:26:58 you know,

1:26:58 we're actually going to find

1:27:00 this is the best indicator

1:27:02 of uh how well prepared a country is for a pandemic.

1:27:06 It's not the ones that we were looking at,

1:27:09 you know.

1:27:10 Um.

1:27:11 And that's the,

1:27:12 and that's the indicator then that we should really be targeting

1:27:16 and trying to sort of improve.

1:27:18 But those are my lay observations,

1:27:20 and I'm,

1:27:21 uh,

1:27:22 so I will,

1:27:22 uh,

1:27:23 uh,

1:27:24 leave the debate uh

1:27:26 to the experts

1:27:28 with,

1:27:29 but I leave with,

1:27:30 uh,

1:27:30 still with a dissatisfaction in terms of whether or not

1:27:34 we are actually learning the lessons

1:27:37 of the pandemic.

1:27:38 And I'm not just talking about the healthcare systems.

1:27:41 I'm also talking about education.

1:27:43 I'm also talking about social protection.

1:27:44 I'm also talking about fiscal policy generally.

1:27:47 And monetary responses.

1:27:49 I'll stop that.

1:27:52 Thanks everyone,

1:27:53 and see you at our next policy research talk.

1:27:56 Thank you.

1:28:00 Thank you,

1:28:00 Dion.

1:28:01 Thank you for sharing so well.

showAllTimestamps

no

transcript

OK, everyone, to not penalize those who actually showed up on time too much, we will get going here. So welcome everybody to our, uh, February policy research talk. We took a uh a break over the, the sort of end of year, uh. Festivities and we're now gearing back up. We have an interesting slate coming up this spring, um. So, without further ado, let's me turn it over to Innermit Gill, the senior vice president and chief economist of the World Bank, who's gonna kick us off today. Over to you, Intermit. Thank you, Dion, and I'm very, very sorry again that I'm not there. Uh, so, I really don't have anything important to say at the beginning, other than to say that I wasn't at the World Bank for much of the time of the pandemic. And I always thought that the bank could have done a little better, Dion. I thought that, I thought that I thought that the bank could have done better in helping low and middle-income countries actually tailor their responses uh to the crisis, both on the health side, but also on the side of social protection, as well as the economic response, the fiscal and monetary responses, instead of copycatting advanced economies, right? So I was very interested to know what Damien and Dana were going to say about the health part of the response, because I really don't know much about it. Uh, but I do know that among the people at the bank who should be talking to us about these things, these are probably the two best people. Uh, so Damien is the acting manager of the human development team. In, uh, the Development Research Group. Um, he, um, he actually has worked on HIV interventions in several African countries. Uh, so he, uh, so it's really good that he turned his attention. To the COVID response, uh, then, uh, uh, the other person you're gonna hear from is Dina Ringold, who is the director for strategy and operations for Human Development. So she's a very important person for making sure that we don't make the mistakes that we made in the past because. Uh, she actually covers both strategy and operations for human development. Uh, she also has been the regional director for human development in Africa, and she actually worked also on the governance of service delivery. So again, The ideal person to to speak about these things. So I was struck, by the way, I was struck by the slides that Damien sent, and I don't want to steal his thunder, but the thing that struck me on his last slide or last two slides was there is no dichotomy between. Good pandemic preparedness and decent primary care, so he says that Thailand and Vietnam had the best responses or among the best responses to COVID-19 because they had strong primary care systems that the population trusted, OK. Uh, so I, I, so I think that that seems to be, that seems to be the key lesson that comes out of it, but I'm sorry, but I'm sorry to steal your thunder, Damien, by saying if that is indeed true, I'm very sorry to steal your thunder. But, uh, but if that isn't the case, I'm going to listen and I'm going to, uh, change my tune at the end. But over to you, Damien, and then to Dana. And please chair the session, Dean. Sure, no spoil but I won't be giving any spoil uh any spoilers, just, OK, over to you, Damien. I Thanks guys. Thank you, uh, very much in the midst for these, uh, kind words, and, um, I assume the microphone works well. If that's the case, uh, let me start and good afternoon, everyone. It's my pleasure to uh present this policy research talk entitled Strengthening Health Systems for Pandemic Preparedness and Other Emerging Challenges. And I want to start this talk with, um, do you see actually. Uh, no, there's, uh. Here, OK, thank you. I want to, uh, start this talk with, uh, this painting from Rembrandt. Um, you can see it in the Mauritzer in The Hague in the Netherlands. The title is The Anatomy Lesson of Doctor Nicholas Torp. I want to start with this painting, not only as a note to my, uh, discussion with from the Netherlands, uh, but also because I want to, uh, apologize to you because I'll be talking a lot about death and mortality. Uh, in Dermid, um, remember that, that I've reminded you that I've worked a lot on HIV AIDS. When I was doing that, people were teasing me and were, uh, telling me, Well, Damien, you always talk about death and sex. I'm sorry, but today I won't speak that much about sex, but quite a lot about death. So my apologies for that. Uh, more seriously, the reason I, I chose that pic that picture is that I want this to start this, uh, talk by doing some sort of, um, an anatomy of the pandemic, the COVID-19 pandemic. And so, The outline of the talk is that I will start with a retrospective look at the COVID-19 pandemic. I will Uh, raise some questions and lessons about health investments from the COVID-19 experience, and then I will switch to the current transition in the burden of disease that uh we are experimenting globally. With the rise, including the rise of non-communicable disease or NCDs. And I will try to look at 3 questions basically how to invest in health to minimize amenable deaths. I will talk about expanding health coverage, but I will also stress the importance of prevention and public health measures and the importance of quality of care. Using the concept of effective coverage. So I would like to start with Contrasting these two numbers on the left we have 5. 9 million deaths and on the right we have 18.2 million deaths. So what are these two numbers? They come from this paper published in The Lancet by the COVID-19 excess mortality collaborators. 5.9 million deaths. Those are official reported official COVID-19 deaths during 2020 and 2021. Where is 18.2 is the estimate these authors are doing of the number of people who died during the same period, 2020, 2021. Because of the COVID-19 pandemic, they are using. Excess mortality methods to come to that estimate. So what are excess mortality calculations? They compare for the same period of interest the number of actual deaths to the number of expected deaths during the same period. The number of expected deaths is a projection based on the number of deaths in the immediately preceding years, and they add to that a linear trend because in aging populations, the number of deaths tends to increase. That's considered as the gold standard in the analysis of COVID-19 mortality. And that using these methods, they obtained this number, 18.2, which is three times larger than officially reported COVID deaths. It's important to realize that these excess mortality estimates represent a combination of different effects. The first one in blue are direct COVID-19 deaths, deaths that are due to an infection with the virus. To that, we add the number in green, which are the indirect COVID-19 deaths, which might be due, for example, to congestions of the health systems, delay in care seeking people because people didn't want to go to the health centers, or issues with mental health. Now, to that number, you also need to subtract what is in brown, the averted deaths. Those are deaths that would have taken place in the absence of the pandemic but did not occur because of pandemic induced measures. We can think, for example, during the lockdowns, there might have been less traffic injuries, less violence, or other infectious diseases. So it's important to realize that this excess mortality estimate. Combine these three components. So I said I will discuss a lot about mortality, but still it's important to acknowledge that the impact of COVID-19 went well beyond mortality. It included, as I mentioned, delayed care, the mental health burden, school closures, learning losses, lockdowns, economic and political shocks. I won't have the time to cover that, but I wanted to acknowledge it. So I want to start by taking some lessons from this comparison between the official COVID deaths and the excess mortality. So, as I've said, the, the excess mortality estimate is more than 3 times higher than officially reported COVID-19 deaths. That basically says that even in the 21st century, our health and civil registration systems are still not very good at measuring. The impact of such a major health event and that's certainly it's a lesson, that's an encouragement to step up our efforts to mainstream civil registration across the world. It would have benefits in terms of measuring the impact of future pandemics, but it has also many benefits beyond an accurate measure of mortality. It's important to register every birth so that the children can benefit from health and social services. Then using these numbers, I will quickly try to see how the deaths from COVID-19 were distributed around the world and try to ask how big of a number is 18.2 million. Obviously it's a big number, but I will compare it to past events as well as compare it to other recent health events. So this is a map showing the distribution of excess mortality. Across the world Only in the country where us where using vital statistics allow such a calculation. So you see all the numbers with the gray shaded color is basically where such a calculation is not possible. But otherwise, looking at the colors and realizing that the closer you are to the dark red. Color, the higher the mortality rate, we see that mortality using excess mortality numbers was highest in Russia and some of the Eastern European countries. It was also quite high in South Africa as well as in Brazil, Mexico, and Ecuador. Coming back to the paper I mentioned earlier in The Lancet, what they've done, so where there was vital statistics available to do the calculation, they are using that. And otherwise in the other countries that were shaded in gray in the previous map, they've done a modeling exercise. And here again, the closer you are to dark orange, the higher the mortality rate. And the green color is lower mortality rate, so we see low mortality in Australia, New Zealand, China, and some African countries, and higher mortality again in Russia, Eastern Europe, the southern corner of Africa. Latin America, especially Peru and Bolivia, as well as Mexico. So if we take these numbers from the same paper and rank them by our World Bank regions and add a category for high income country, this is what we get in terms of excess mortality per 100,000 people. In East Asia, excluding China and and sub-Saharan Africa, mortality was lowest. Then comes the group of high income countries, and then not very much higher, MA, South Asia, and quite higher. Latin America and the Caribbean as well as ECA. So in a paper that we published with Gabriel whoisi and other quarters, colleagues at the bank, we use both official COVID deaths on the left and excess mortality estimates on the right to look at how COVID-19 mortality. Was distributed by age groups, and we've ranked the countries in descending order of income with middle income at the top and richer country, high income countries at the bottom. We use colors to show, uh, so all the share of death among individuals younger than 65 is in. Orange or brown, so working age people, the share of deaths among older people older than 65 is in different shades of green, and what we see is that in the middle income countries, the share of death at younger age is higher. And that's controlling for the age structure of the population. So basically, mortality affected more working-age individuals in middle-income countries than in high income countries. I want to step back a little bit and look in history. And compare the COVID-19 pandemic with the Spanish flu or Spanish influenza that took place about 100 years before COVID-19, between 1918 and 1920. So on the left here you have the two numbers I've already given you 5.9, 18.2 million deaths, the two estimates. It's quite difficult to estimate mortality from the Spanish flu, but historians. Agree on a central estimate of about 50 million individuals and the period was about the same length and then that's the number in the middle and then the two numbers on both sides are the low and the high estimates from historians. So of course the world population was much smaller 100 years ago. It was estimated to be about 1.9 billion and currently we are about 7.9 billion. So to do correct comparison, you should divide the previous number by the size of the population, which I have done here. And we see that the difference is even starker in terms of mortality rates. The mortality rates were much higher. 100 years ago. So, of course, we should expect that. Because we should have done better because over the last 100 years there has been a tremendous progress in life expectancy as shown from this picture just showing life expectancy over the last 100 years. The dark green line is for the world as a whole, and then you have this different line for each continent. And we see the levels are different, but the trend is the same with Gradual increase and substantial increase in life expectancy. So we should have done better. But even accounting for that, I would like to argue that we did better than 100 years ago, and I would like to argue that the vaccine played an important role in this. So let's remember from the day the scientists. Performed the genomic sequencing of the virus to the first approval of a vaccine, there were only 326 days. That's very little by historical standards. So in a paper in The Lancet, Watson and Coulter tried to estimate the global impact of the first year of COVID-19 vaccination, looking at the period between December 2020 and December 2021. Again, they use the two methods that I've described before, using the official reported COVID deaths as well as the excess mortality estimates. Using the first method, the officially reported COVID-19 deaths, they estimate that vaccination prevented 14.4 million additional deaths. The second, using the second method, they estimate is higher, 19.8 million additional deaths. So basically, vaccination more than halved COVID-19 mortality despite being introduced one year after the start of the pandemic. Another way to look at the benefit of vaccination is to do returns on investment calculation. That's what SAR and others are doing for the New York City COVID-19 vaccination campaign. Looking at the period between December 2020 and January 2022, they first calculate and estimate the cost, the direct cost of the vaccination campaign, also the indirect, including time lost to go for vaccination, time lost due to side effects of vaccination. Their estimate is $4.8 billion. Then they do two calculations for the benefits. The first one is just adding. The direct and indirect healthcare costs. And that they come to close to 28. billion dollars and. Later next, they also want to account for the lives saved. Using the value of a statistical life methodology that is developed by economists to calculate how much people would be willing to live one more year and doing this, they come to additional saving of $26.3 billion. So they calculate two returns on investment, including the value of the mortality saved. $1 spent saved $10.19 that's a return on investment of 1,019%, and without the life saved, $1 spent saved 4.27. Dollars that are returns on investment of $427 a point of comparison. The return on investment in the technology sector in the US was 16% in 2022. I should add that this calculation doesn't account for the potential cost of lockdowns, school and business closures that could have occurred in case of no vaccination, so it's probably an underestimate. So I think it's fair to say that COVID-19 vaccines were a game changer. But we should acknowledge that globally we encountered problems with equitable manufacturing and distribution. My colleague Tristan Reed gave a policy research talk 2 years ago about this topic, so I will, I will not cover it. I would refer you to it. And also, as we campaigned for vaccination, we encountered in many countries vaccine hesitancy, which is linked to the trust in the health system. Which if not addressed, might have lingering effects, including for other diseases. So it's important to verify whether and to what extent vaccine hesitancy has spread. To other well established vaccines, including childhood immunization, for example, in December 2023, there was an outbreak of measles in Kazakhstan, and there is some indication that this might link to a lower rate of vaccination for measles among children. So, I will, as I move towards the end of this retrospective look at the COVID-19 pandemic, I want to draw three main lessons. The first one is a very basic one, a very simple message, which is it pays to invest in health. I've given you some examples. There's something we knew at the World Bank, at least since the World Development Report in 1993. Entitled Investing in Health. And We can debate whether the World Bank could have done better, but our institution delivered on this premise from April 2020 to March 2021. The World Bank Group committed over $200 billion to public and private sector clients to fight the impact of the pandemic. Second lesson I want to take is that government play an important role, an important role. But individual behavior still matters a lot, so the government played a role in Establishing and enforcing lockdowns. In some cases maybe not enough in providing social support during those lockdowns, in maintaining essential services during the crisis, even if those services were under stress. I'm thinking, of course, first and foremost at the hospitals and also in purchasing the vaccine and distributing them. The private sector also played a role. I'm thinking here about the development and the manufacturing of vaccines, but we've seen that individual behaviors still matter a lot. Most of us want to be vaccinated, but as I've discussed, there was also vaccine hesitancy. Most of us followed lockdowns and mask mandates. But there was also some resistance. For example, this paper by Abaluk and others shows how interventions to persuade people to wear masks were important in Bangladesh. Third lesson is that trust matters. So I'll illustrate this using first a paper by Asano and others. They use people voice surveys, phone surveys in 14 countries ranging from low to high income. They find that greater healthcare use, having a regular and high quality provider, using other preventive services, confidence in the health system and in the government, positively correlated with COVID-19 vaccination. There is also some evidence that countries which had been confronted and responded to previous epidemics such as the SARS epidemic in East Asia in 2003 and the Ebola epidemic in West Africa between 2014 and 201616 were better prepared. There is also some evidence about the role of politics in building trust or not building it. I'll mention two examples without going too much in details. I'll mention Brazil and the United States. So let me finish about COVID-19 by just giving you some perspective about That famous number of 18.2 million deaths that was for the period 2020 to 21, 2 years for COVID-19. If we compare with HIV AIDS over a much longer period, more than 30 years between 1991 and 2022, the estimated number of deaths is 14.4 million. And then Ebola that I just mentioned in 2014 to 2016. The death toll was 11,325 individuals, and SARS in East Asia in 2003 was 774. No, I want to take this number of COVID-19 estimated excess deaths and just focus on the excess debt in low and middle income countries. That's the number here on the top on the right is 15.6 million for the two years, 2020 and 202021. And I will pivot to other disease by comparing this number that happens to be the same by chance. To the number of total avertable deaths in low and middle income countries, so those are deaths that could have been avoided. Uh, in the year 2016, just, uh, one year, but it's just before COVID and it happens to be the same number. So look, let me take that number and further decompose it. That's what I mean, that's what Margaret Kirk and others are doing in this paper published in The Lancet. So they take this number of total avertable deaths, 15.6 million for 2016. What they first do is they compose that number between deaths that are amenable to healthcare that could have been treated in healthcare. They come to the number of 8.6 million or 55%. And then, and then that's prevented. Sorry, deaths preventable by public health intervention, that's 7 million or 45%. Then the number of deaths amenable to healthcare, they further divide it into two categories the deaths due to the non-utilization of health services. That's 3.6 million or 23%, and the deaths due to use of poor quality services, that's 5 million or 32%. So I'm not going to go too much into the detail of how they are doing this. It's another use of excess mortality. What they are doing, they're using data from the 2016 Global Burden of Disease study. And they calculate mortality amenable to personal healthcare for 61 SDGs, medical conditions, and they compare the case fatality. The case fatality is the number of deaths. Divided by the number of people suffering from a specific disease, they compare this case fatality between each low or middle income country with the corresponding case fatality for 23 high income reference countries with a strong health system. They further used data on healthcare utilization from population surveys to separate the deaths due to non-utilization and deaths due to poor quality. If we take those numbers. And divide them by region. This is what the picture we are getting. So in dark blue, we have the deaths per 10,000 people due to low quality of healthcare. In light blue, we have the deaths due to non utilization of healthcare. And in yellow with deaths due to insufficient prevention, issues with individual behaviors, environment, or lack of preventive care. There are two main messages from the paper. The authors, they mainly focus on quality of care. They say that in low income countries, expanding healthcare coverage does not necessarily result in better outcomes, even for conditions highly amenable to medical care, and therefore health system quality must improve. I fully agree with that message, but I would, that quality of care matters, but I would like to add also the one that prevention and other public health intervention matter. So to finish with the estimate from this paper, here is a map showing. In the world where the mortality due to poor healthcare quality is highest, so the countries in gray are the 23 reference countries with strong health system, and then the closer you are to the dark blue color, the higher the mortality due to poor quality of care. We see that's highest in many countries in Africa, especially. In countries in West Africa and Central Africa, it is also quite high in Afghanistan, Pakistan, and India in South Asia. So no Moving to other disease than COVID-19, it's important to realize that COVID-19 occurred in the middle of a transition in the burden of disease. Overall, the world experienced a rise in the. Of noncommunicable diseases, also called chronic disease such as cancer, diabetes, hypertension, heart condition, and others, their characteristics are that they are of long duration and for successful treatment, it's important to have early detection. NCDs will become even more prevalent with aging populations. Non-communicable disease kills 41 million people each year. That's equivalent to 74% of all deaths globally. I'm not, I don't like too much that statistics because Unfortunately we know we'll all die and we'll all die of something, but I think it's more important to focus on premature deaths. So the second statistic I think is more telling. Each year 17 million people die from an NCD before age 70, and 86% of these premature deaths occur in low and middle income countries. As I sketch this transition in the burden of disease, I also want to mention the consequences of climate change on health, including air pollution, droughts, heat waves, etc. I won't have the time to discuss this in detail today, but I wanted to acknowledge it. So let me sketch this transition in the burden of disease using 3 of these graphs. Here we are looking at low income countries and we are not looking at deaths this time. We are looking at DALIS, which is the acronym for disability adjusted life years. So it's the number of years lost because of a disease and it's adjusted for the years you live with a disability because of the disease. It's millions, we go to the period from 1990 to 2019. I'm not going to go over the list of diseases, but on the left we have the communicable disease, including also the maternal disorders, neodental disorders, and others. On the right we have the communicable disease that I've mentioned before, hypertension, cancer, cardiovascular disease, diabetes, etc. What we see in low income countries is over time a decline in the share of the burden of disease from communicable disease and a gradual increase from The NCD on the NCD side, it's still important to note that in the low income countries, the total number is still higher on the communicable disease side. So I don't want to discount the importance of communicable disease, especially in low income countries, but the trends are clear. Same picture for lower middle income countries. The trends are the same decline on the communicable disease side, increase on the NCD side. Here, the total number by the end of the period is actually higher on the NCD. And then finally the picture for upper middle income countries, you see a stark decline in the share of the communicable disease in the lost dallies and an increase in the in the numbers and the share for the NCD. So of course those numbers were stopped in 2019 before COVID. I've just said, you know, a rise in the share of non-communicable disease and COVID-19 was an imminently communicable disease, a new one, so that sort of changed the picture, of course, at least for two years. But it is also important to note that there are important interaction between COVID-19 and. Non-communicable disease. People suffering from NCDs are more vulnerable when they are infected by COVID-19, more likely to end up in the hospitals or to die. We are learning about long COVID that might be a new chronic condition. We've seen the health and mental health consequences of the lockdown as well as the non-health consequence of the lockdown on poverty and education. So COVID-19. I've tried to argue, reminded us that it pays to invest in health, but what I'd like to do is to spend the rest of my time trying to ask how best to invest in health, given the transition in the burden of disease that I just presented. So I think the transition in the burden of disease. Stress the importance of prevention first. Prevention is more effective in terms of disability adjusted life years. That is saved, and it's also more cost effective than treatment. Prevention can take place at two levels. First, at the population level. And then at the interaction between the population and the health systems where both the demand and the supply side can play a role. So let's first think about the intervention at the population level, so-called public health intervention. One first set of interventions aimed at reducing risk factors. We're thinking about reducing smoking, alcohol and drugs consumption, unsafe sex, bad eating and drinking habits. Or they could also increase good habits, good health habits such as exercise, healthier nutrition. They could encourage hygiene and for example, mask wearing during pandemics. It's important to note that this type of intervention ever benefits not only for the individual, but also for others since there is a positive externality. There is also intervention to reduce environmental exposure. We are thinking about reducing unsafe water, pollution, etc. In terms of pandemic preparedness. Epidemiologic surveillance is very important, being able to detect when a new virus might occur, a new outbreak of a known virus might occur, and for that, the concept of one health is important. One health is basically looking at the same time at human and animal health and their interaction. We know that many of the recent pandemics were triggered when a virus jumped from animals to humans. So these interventions are mainly on the demand side. It's first about providing information. When it's not sufficient, Financial incentives could play a role. We can think of cash transfer potentially, but I would argue that when feasible, especially for bad habits, taxation. the most efficient instrument we've seen that tobacco taxation was very instrumental in reducing smoking rates. There are many experiments currently with taxation, for example, for sugar sweetened beverage. There is also some role on the supply side for supply side intervention, for example, the vaccination campaigns. Prevention also occurs at the interaction between population and health system and where both demand and supply side can play a role. We're thinking about antenatal care, stressing how important it is for pregnant women to come to regular checkup before they deliver. Immunisations. I've mentioned the COVID vaccine, but there are also all the child immunization or the flu vaccines for adults. I want to take this opportunity to celebrate the introduction of the new malaria vaccine for the first time in the official child immunization calendar in Africa that was in Cameroon at the end of last month. Also very important is the early detection of non-communicable disease such as cancers, hypertension, etc. It's important also to address antimicrobial resistance, which can be triggered by misuse or overuse of antimicrobial drugs. So here again we need information on the need of preventive care. People should know that it's important, for example, to do regular screening for chronic disease. But when it's not sufficient, financial incentives could be used, for example, cash transfer, but sometimes simpler and cheaper intervention such as personalized invitation can be as cost effective. So I'll give you one example from a study we conducted with World Bank colleagues in Armenia where we compared personal invitation and cash voucher to encourage hypertension and diabetes screening. We on the left here, so we are looking at individuals who are aged 35 to 68, that's the age when people are supposed to do a yearly screening for for hypertension and diabetes in Armenia. We looked at people who are not been screened in the last year. And we followed them over six months in the comparison group, just 3.5% of people screened. In orange you see people who had received a personalized invitation, with an invitation signed by a doctor, by their doctor, telling them how, where and when and under which condition they could come for the screening, and that the screening was free. You see that the screening rate increased by 15% points to 18.5%. And then there was another intervention. Where to the invitation we added a $10 conditional voucher. They could redeem the voucher in pharmacy chains and basically we told them if if and only if you are coming for the screening, we will give you after that this $10 voucher and we see that the screening rates sort of Increased by another 15% points, so the impact was larger if you add the conditional voucher, but when we looked on the right at the average cost per person screened. There we see that because the conditional voucher of course cost $10 and you needed to bring it, the average cost per person screened was similar above about $60 a little bit more than $60 per individual. I went here to make an aside about obesity, so we all know about the new drugs made from semaglutide, the brand names Ozempic and Wegovi, and a fair question is whether they are a game changer. So we know obesity is important and it's killing many people, not only in rich countries. On the map here on the left, you see the share of deaths attributed to obesity in 2019. And the closer you are to the red color, the higher it can go up to 30% in some of the countries in the Arab world, but in many other countries, we have a large share of deaths attributable to obesity. So it's an important issue in many countries in the world. But the current prices are quite high. They are between $215 and $700 a month, and you could say that's way too expensive for low and middle income countries. Isn't it better to focus on prevention and behavior change? My answer is maybe, but that debate reminds me of a debate that took place when I joined the bank around the the early 2000s, where the same reasoning was made for antiretroviral treatment for HIV AIDS patients. The prices were sky high and people were saying. Low and middle income countries cannot afford that. We should focus on prevention and behavior change. Turns out the price went down and no anti-retroviral treatment is available everywhere. And it's estimated to have saved 18.6 million lives between 200 and 200 and 2021. No, I will finish this talk by looking at the quantity and the quality of healthcare. Um, some of the dividends I will take is coming from a policy research report that we wrote with many authors here at the bank, uh, entitled Improving Effective Coverage in Health Do Financial incentives Work. I presented with Eugenie Camp Paldi. Report in a policy research talk in May 2022. So if we look, if we think about the quantity of healthcare or health coverage, it's first a supply side issue. We need the right number of health centers, of doctors, nurses, the right equipment, but even when centers are well staffed and well equipped, staff must provide sufficient effort. It depends on their intrinsic motivation, but also on their extrinsic motivation, their salaries, but also the potential role of performance-based financing or PBF. Our institution, the World Bank, has invested substantially in that reform, and that report is looking at the evidence. I won't go into the detail, but note that even if you make an effort on the supply side, there is also the need for patients to come to receive healthcare, including for preventive care. So for uncomplicated case, financial incentive for patients to visit primary care facilities could be used and have been used. So that's what we are looking in the report. In that exercise, we compared financial incentives offered to patients to visit clinics on the demand side. We compare them to incentives offered to providers to increase and improve service delivery, uh, like performance-based financing on the supply side. So we did this exercise for maternal and child health services. What do you have in this? Graphs on the right side you have a demand side intervention, conditional cash transfers. On the left side you have a supply side intervention, performance based financing for health providers. In the middle is a voucher which is a hybrid between the two. The patient receives a voucher that they can use to receive free services, and then the health center. Cash the voucher. We look at 6 maternal and child health services, modern family planning, facility delivery, 4 antenatal care visits, 1 postnatal care visit, maternal tetanus vaccination, and full child vaccination. What do we see overall positive effects most of the time, but not always statistically significant as indicated by the stars. But the effects are overall a little bit modest, and if you look at the point estimate. If anything, the point estimates are somewhat larger on the demand side, the CCT side, and the vulture side than on the supply side. Let me then look at quality of care, using the concept of effective coverage. It's a concept that requires that everyone in need of a particular health service is getting it in a timely manner and at the quality necessary to obtain the desired effect and the potential health gain. So it's basically we go from utilization, which is the percentage of the population using a service. To coverage which is the, which is the population in need using a service to effective coverage, percentage of the population in need using a service and getting the optimal treatment. I'll show you using an example. The example of hypertension in 5 East Asian countries that you can miss an important part of the picture if you only look at quality or quantity. So we start with quantity or coverage. So we are using WHO step-wise survey. We are looking among the people who suffer from hypertension. The survey measured their blood pressure, the percentage which receive treatment, and you see it varies a lot. It's quite high in Cambodia and Vietnam, but it's much lower in Mongolia, Myanmar, and Timor-Leste. Next we look in orange at quality. Quality is the Among those who receive treatment. The percentage with their high plantation under control, and here the picture is somewhat flipped with better results in terms of quality for Myanmar and Timor-Leste. But I would argue that the two numbers are misleading or not sufficient. What you need to do is multiply the two numbers, get their product to get at effective coverage. That's what we do here when we multiply the two numbers. We get the number in gray. And here clearly the numbers are fairly low in Cambodia and Vietnam. It's between 10 and 20%, and it's below 10% in Mongolia, Myanmar, and Timor-Leste. So to finish with quality of healthcare and effective health coverage again, it's first a supply side issue. You need to train high quality doctors and nurses. You need high quality equipment. But even when well trained staff and well equipped health centers are available, staff must provide sufficient effort to reach minimum quality. Again, it depends on intrinsic and extrinsic motivation, and performance-based financing might play a role, but patients could also be better informed of what minimum quality standards are. And which facilities satisfy them so we could think of information interventions. Now let me finish by um. Repeating the first, the three lessons I took from the COVID-19. The first is a simple message that it pays to invest in health. The second one is that government play an important role, but individual behavior still matters. And the third is that trust matters. So here is the thunder that Imit stole that there is no dichotomy between pandemic preparedness and primary care. Thailand and Vietnam offered one of the best. Response to COVID-19 because they had a strong primary care system in which the population trusted. My main message in terms of universal health coverage. Is that the quantity and the coverage of healthcare providers remains important. But prevention and public health measures could help avoid a large share of the burden of disease, especially with the growing share of NCDs, and that quality of care is at least as important as quantity. And I'll finish with this main policy message. Prevention is key, especially but not only given the rise of NCDs, the importance of vaccination, of public health measures such as information, but also taxes. On unhealthy behavior and the importance of early screening. Quality of care must be an essential component of universal health coverage, and quality of care builds trust in health systems. And finally, strong primary healthcare systems are the foundation of pandemic preparedness. Thank you very much. Thank you, Damien. That was an incredible amount of of of territory that you covered. Uh, and Dina's gonna respond to each and every point you made. No, uh, Dina, over to you. Uh, just after Dina's, uh, given her comments, we're gonna open it up for Q&A in the room. If you're online, feel free to sort of raise your hand virtually or put a comment or question in the chat and we'll manage, um, as we go forward. So Dina, over to you. OK, thank you, um. Intermit Dion Damian for the invitation to be part of this. Um, this was extremely, uh, thought provoking and, um, really a chance, uh, to reflect. Um, I should start by, uh, giving the caveat that I am not a health specialist. Um, so my perspectives come. Um, from my experience, uh, as HD regional director, um, during the pandemic, uh, covering West and Central Africa, um, where I learned a lot, uh, on the job, um, and then currently as HD, uh, director where, you know, I think we're still trying to come to grips with, um, uh, what happened. And so I think this kind of a conversation is, um, uh, extremely helpful for, for reflection. Um, and, uh, so, let, let me just start by saying that I think it's really welcome that we're talking about the lessons from the pandemic. I feel like this is a topic that no one, Gabriel and I were discussing. No one really wants to talk about anymore. We, I think we all. All went through it and we want to move on, um, but I think that leaves us in, you know, the difficult place of, uh, panic and neglect, uh, conversations, um, and I've, uh, sorry, I need to tell whoever's trying to reach me that I'm not talking on the phone right now, um, so, uh, I, I, we're having these, we're reenacting some of the panic and neglect conversations about the need to invest in pandemic preparedness that we had. Well, before COVID, um, they're coming back. So I think it's really important to remind ourselves why, why this matters. And, you know, I think it's really striking that, um, uh, there was a, uh, uh, work by CGD that suggests that there's, um, a 50/50 chance of another respiratory pandemic on the scale of COVID during the next 25 years. So we're all likely to go through this again, um, which is terrifying. I think it's also striking. um, the, the mortality, uh, findings that you shared that, um, there's very little correlation between the global health security index and preparedness and how countries fared, uh, during the pandemic and that, um, really trust is key and so I think in thinking about, you know, the so what and what do we do putting that front and center, um, is, uh, very important but also extremely challenging. Um, so just reflecting on my own experience, I think these trade-offs that you're pointing to between the need to invest in pandemic response and preparedness and health systems and quality of care are real. And when I was, uh, going through this in the Africa region, I really saw firsthand how countries struggled to respond to the immediate needs of the pandemic and manage weaknesses of, uh, health systems that, that really were fragile or non-existent. Um, And you know, I think there were two kinds of, at least, uh, there were lots of different kinds of countries, but two come to mind. One is that, you know, there were countries that had existing healthcare systems, primary healthcare, um, like Cabo Verde, which was one of the countries that I got to visit during the pandemic. They had, I mean, it's a very small island country, uh, well resourced in, in, in some respects, but they also had extremely strong. Um, primary care, and they were able, once they got access to the vaccine, which is another story, they were able to ramp up to, you know, far surpass OECD vaccination rates, um, really, really quickly. So having that system in place mattered a lot. The second was countries that were able to, um, use. Uh, the pandemic response to reinforce, uh, and, and, and, and strengthen aspects of their systems, even if they were weak and, and really go through a learning process. And the one that comes to mind was, was Cote d'Ivoire, which was the first country that I visited, um, in November 21. And, um, their initial vaccination response was really slow. They had access to vaccines, but they just couldn't get them out. And so they did some thinking about why that was and started to really get to the population. So they had mobile vaccination clinics, um, they, uh, expanded, uh, centers, um, in, in communities, and they were able to catch up, um, pretty quickly and be one of the countries that had a Higher, um, uh, rate of vaccination. So, I think, you know, these interactions that you point to between, you know, pandemic response and, and, and, uh, health systems and, and health services are, are really, uh, really important and, and, um, you know, I think the, the tragedy in, in, in Africa was, you know, that for quite a few countries, the pandemic really put health systems under strain and this led to further gaps in, you know, basic immune. ization uh, coverage, non-COVID, childhood vaccines, and, and other kinds of drops in access to services. Um, so you talked about, you know, strong primary health care as the foundation of pandemic preparedness. So, so these things being linked now my colleagues in H&P and some of you are here and I hope Tim and others will speak up during the. Uh, the conversation, we call this resilient health systems, really packaging prevention and, uh, preparedness together with systems that are able to, uh, respond. It's really this, um, this sweet spot of win-wins that you pointed to in the case of, um, you, you mentioned Thailand and, and Vietnam. So just thinking about, you know, what we can do to help countries get to, uh, these win-wins and, and build resilient, uh, health systems. I think there's maybe 3 areas. One is around financing and you have your headline, it pays to invest in health. I think that's great. Um, obviously the challenges are real in, in lower income countries, um. Uh, you know, less than 2% of GDP is spent on health, and we know, um, because of work that colleagues have done that, um, because of the fiscal outlook in developing countries, this is unlikely to, uh, increase, uh, uh, between now and 2027. Uh, their projection is that health spending is going to remain at about, uh, COVID or pre-COVID. Levels so fiscal space is really uh limited and so this is really uh exercise in thinking about how countries can spend um more if they can, but more importantly how can they um invest better and how can they think about some of these trade offs and I, I think you know that's the um challenge that your presentation gives us is, you know, given. Uh, the, the needs and given the shifting burden of disease, you know, how do you prioritize, um, specific, uh, trade-offs in, in health investments, um, which is, I think the second area, you know, what are the investments that really add up to. Uh, resilient, um, uh, systems that, that respond to shifts in the burden of disease and also increasing health emergencies and, and, you know, we're talking about pandemics, but I think, um, uh, you know, the climate risks and, and the, um, uh, need for countries to build, uh, resilience to, uh, climate related health challenges are, um, uh, just as, as challenging. So I think one element of this, which I think it gets at this point you made about the interaction between the population and health systems, for me is around investing in, um, the health workforce and community health workers. I think that's important not only for, you know, the kinds of services they can provide, but it's community health workers who are also able, um, to, uh, contribute to trust. And, you know, I think there's some. Examples and anecdotes from, from the pandemic, um, you know, Nigeria, for example, was able to mobilize 50,000 community health workers who had been trained to deliver polio vaccines to deliver COVID-19 vaccines. So, you know, having these, um, people who can be trained and retrained and sent out to communities, um, to deliver services, um, is, is really. Important. And I think, you know, if you look at our health portfolio, we're increasingly working in this area and thinking through, you know, the, uh, the supply side incentives for providers and the issues around, um, you know, behaviors of providers and, and, and incentives and quality, but I think this is an area where, you know, we, we need to think together about what, what really works. Um, I think it going continuing on this idea of trust, I think some of the. Work of the embed unit and thinking about behavioral, uh, uh, interventions. Um, we saw some thinking about this during the pandemic and, you know, what nudges and messaging and, and engagement with, um, people in communities leads to, um, uh, less hesitancy around vaccines and more take up. I think there's a lot there to, to think about, especially at this intersection. That you talked about. Um, the other is, uh, what technology can do and, and the role of, um, dig digital and, and AI and health, um. One of the examples in the collapse and recovery, uh, report that that Norbert and colleagues did on the impact of the pandemic, one of the examples there is in Pakistan where, um, in the first year of the pandemic, uh, uh, over a million kids were, um, left unvaccinated, but they were able to use an electronic registry of immunization to find kids and vaccinate them, and they caught up pretty quickly. So, you know, what are these instruments that can. Um, leverage technology to, um, uh, to, to help, um, health systems be more, uh, uh, agile and, and, and resilient, um, and then I think the third, uh, area is around, uh, increasing equitable access to, you know, the kinds of medical countermeasures like vaccines that you talked about, and I think there's a lot of lessons and I'll watch Tristan's, um. Uh, talk that you link in, in your report because I missed that. But, you know, I think I completely agree that the rollout of vaccines was a game changer, but in our countries, it was, it was a real struggle, right? So, um, you know, 45% of Americans got access to one dose of the vaccine before 1% of Ethiopians did, right? So, and that's just, you know, one number. It was really striking how, um, uh, African countries and developing countries at large really lagged behind and we were able to respond through things like, you know, the innovative partnership that we had with the African Union under the AVAT arrangements and the bank was able to, you know, help countries, um. Uh, get access, um, uh, he, he just, uh, retired, but, um, uh, Enzo, you know, our chief procurement officer was just, uh, incredible at helping countries, you know, connect with pharmaceutical companies to get contracts and, and all of this, um, was, was very important. But as we think forward and, and think about how the bank can do better next time. I think, you know, questions around should we be, uh, together with IFC, um, helping countries build manufacturing capacity so they can more quickly, uh, get access to vaccine. What kind of at-risk financing mechanisms are there so that the bank can help countries, um, Uh, compete on a level playing field in the market next time they need to get, um, uh, vaccines, uh, and so on. So, um, I think this is, these, some of these ideas are, you know, that I threw out in the area of what makes a resilient health system are very much embedded in the, um, health emergency preparedness global challenge. Program, which you may have heard about. And I think you, you know, we're already working with DEC on some elements of that around impact evaluation and what kind of a monitoring framework, and I really think we need, um, to continue that. There are sort of three areas that are envisaged under that, um, global challenge program, which, you know, are going to be made available to, to all countries, um. The first one's around core public health, uh, services and systems, and I think, you know, there's a very blurry line, as you pointed to between what's primary health care and, and what's essential and what's around preparedness. I think they're, you know, they really go together. The second is around access to financing and the third is. Around, um, you know, what are the, the tools, the, the, the countermeasures, the vaccines, diagnostics, um, and others, uh, things that countries need to be able to be prepared, uh, for any kind of health emergency. So, um, we're joined at the hip, I guess, on this, and, um, thanks so much for inviting me. Thank you, Dina. And, and, and thanks for bringing up the Global Challenge Program because in fact this is the first of what I hope is uh several PRT's policy research talks that we do that are actually linked to the GCP. So I don't know if you, it was subtly in the title that this was a global challenges research insights talk and we hope to have a few more of them actually on, on, on all of the GCPs. Um, so let's open it up. I see intermit you've unmuted yourself, so I presume that means you're chomping at the bit for a question. Um, I have a question, but I can wait for the others. The others are actually, um, yeah. Well, when you start, are there any questions in the room if you want to just raise your hand so that I have a sense of Uh, OK, there's a couple in the room. So in a minute, why don't we start with you, we'll do a few more in the room and then please, if you're online, please raise your virtual hand or, or let me know in the chat that you, you, you, you have a question. So in a minute, you, you, you kick us off. So, you know, um, um, So I'm going back to the point that I see in Damien's PowerPoint, which was the, that Thailand and Vietnam had strong primary care systems. So I was thinking, OK, strong, let's say that strong means strong has a quantity aspect to it, and strong has a quality aspect to it. So my question um to him was, like, you know, say that you have, uh, or during a pandemic, relative to normal times, does quality of care matter more than the quantity? Because then I guess if the answer to that is yes, Damien, then one of the best ways to prepare for a pandemic is to continue to invest in primary healthcare. Rather than something, uh, you, you know, uh, something which is specific to, uh, specific to a pandemic. But invest more in the quality part, as compared with a situation where you're not expecting to have pandemics, for example. Stop that. OK, thanks. I probably usually we actually turn it back to the speaker right after the the discussion. I'm sorry. So we'll we'll incorporate any responses to DNA in this round if you if you don't mind. Apologies for that. Tim. Uh, and then Jed and then Gel. Sure, uh, thanks, Demia, and, and glad that, uh, you're not talking about death and sex, you're talking about, uh, death and taxes, so you've got, got an additional aspect there. Um, so yeah, uh, we worked together in the early 8 things in Brooking and elsewhere, so it's great to hear your perspectives, um, maybe an observation and, and perhaps a question, um. I, you know, great to be bringing evidence on this. I think there's a challenge both in messaging and even in these GCPs on how to frame this kind of interaction between pandemic preparedness and health systems and in a sense it's a, it's a more complicated challenge. It's more difficult than health and say education. We just talk about learning losses and skills because in health we say, well, there's pandemic preparedness and there's health system strengthening and there's primary care and there's climate resilience and I, I think sometimes the, the messaging gets. You know, and that distinction is, is challenging, and, and I think it's non-trivial because as we move into this GCP, you know, global challenge program, there will be those thinking if I'm doing a global challenge program focused on, you know, as a country director says as long as I'm doing pandemic preparedness and strengthening my laboratory and other systems, then. I'm good and the health specialists will say no, you need to be looking at the systems um and so I, I think there's a messaging issue but there's an evidence issue and I'm wondering, do you, do you have anything coming out of the, is there more we can say on the evidence side about the relative balance or the importance in terms of the type of pandemic, you know, including as you move from a focused pandemic, you know, outbreak like. Uh, Ebola or, you know, SARS, where, you know, rapid response and control to where you're in a much more generalized situation where, you know, it's no longer about border control, but it's about the entire health system's response. Um, I mean, do we have any insights there's a way that we can bring in the evidence to think about that, um, and then I think there is a challenge on, on the overall messaging, um, other topics would be interesting to, to discuss, but I think that's, that's something I'm kind of, you know, wrestling with a little bit. Thanks. Great, uh, OK. Uh, thanks Damian for the great talk and Dina for the fantastic comments. Um. Just uh another thought to throw into the mix that's already been started by Intermitt and and Tim. Um And I of course don't want to take away from the usefulness of investing in health systems because as you're arguing, investing in pandemic preparedness are in many ways is a general investment or can be seen as general investment in health systems with many returns. Uh, but from the pandemic averting or, or, uh, minimizing perspective, you did mention briefly the importance of the human-animal interface, uh, either with wild animals or with domestic animals. And I guess the layman, the layperson in me would think, well, that could be a very efficient use of funds to try to minimize contacts there since most likely the next pandemic will come from a, from a, you know, zoonotic origin. So, I, I'm not familiar, but can you speak a bit about the relative cost effectiveness of investments in that domain as well? Thanks. Thanks, Chad. Let's go to Gabriel and then we'll turn it back to Damien and then we'll open up for another round. So please think of your questions. Yeah, yeah, so just, um, I think echoing kind of every, everybody else and in particular, Dina, I mean, on this sort of general point that I think it's, you know, it's quite frustrating that the pandemic is so much in the rearview mirror now and we just haven't been doing this sort of analysis of what happened, what do we do right, and, and what can we do better next time. I think that covers a whole lot of ground including on the, the health response and just on this question, I mean, I, I, I definitely. I want to believe the basic idea that investing in the health system is going to help with pandemic preparedness, uh, but I'm skeptical of that. I mean, since we're among friends, I think I can, uh, express my skepticism on the general point. I mean, I, and I, we look, I know we all look at the pandemic in terms of our own personal experience and, uh, uh, with the bank, so I was in Manila, uh, at the beginning of HTPL. So January 2020, we're all kind of looking around to say, OK, how do we evaluate this, how do we evaluate how well our countries are prepared, and the, the go to reference was the Global Health Security index. So we're, we were going country by country and saying, OK, the Thailand looks pretty good, Malaysia looks pretty good, Philippines, not, not so clear. And then, you know, maybe six months later, uh, or later in 2020, you know, I looked at. The correlation between the GHSI and outcomes and that was 0 and that's, and there's now a bunch of papers which show the same thing and as you pointed out, the one thing which really comes clearly through in any kind of cross-country analysis is that a trust measure so countries that have higher measures of trust that did, did better, but nothing in the GSHSI which is sort of a bunch of measures of basic healthcare quality and, and quantity. And then when I was in Colombia a couple of years later, the team did a pandemic preparedness report looking at all the questions of pandemic preparedness for Colombia, and their set of recommendations was basically improve the healthcare system in many, many different ways. And so I sort of put those two things together, you know, my, my feeling was, well, how, how do we know these things are actually gonna help for pandemic, uh, preparedness, and I still, that's still the question that, that I have. And I also worry a little bit. That selling that health system's investment story is going to cause us to neglect other things that we could do in terms of pandemic preparedness where we do have a little bit more evidence. I mean, 11 thing, for example, is wastewater, uh, monitor surveillance. I, I think the evidence is pretty clear that that's low cost, high, high benefit, you know, also a benefit not just during the pandemic but also for understanding general disease trajectory at other times. So, so, I just want to share my skepticism on that, on that major uh point. Thanks, back to you, Damien. Yeah, uh, thanks a lot for the comments, questions. It's a lot to cover and to answer I. Apologies if I, if I don't do it, uh, fully, so, uh, then uh some, some quick, uh, response, uh. So on the yes I mean there is the the issue of financing in the fiscal space and maybe we had some some uh increase of that fiscal space during COVID and now we are back to before that's a little bit this panic and neglect cycle, um, one point is that for example the so-called sin taxes that I advocated are a way to increase the. The fiscal space. I mean, in some countries where not many people are smoking or not people like in Africa or not people, many people are drinking soda, that might not bring a lot of money, but that's that's one way where it's a win-win. You increase the fiscal space. Um, and you, uh, and you reduce, uh, unhealthy, uh, behavior. Uh, the community health workers, I, I fully agree that's something I wanted to cover and Don told me you're already covering, uh, a lot, but I think that, I mean, that there's a lot of evidence, especially when we don't have enough, uh, doctors and nurse that, uh, we could do a lot more with community health workers. There is an important issue. Uh, is that is are you compensate them, and I know we have the issue of the, but, but most of the. Successful experiment with community health workers have been like from um special interventions from donors where they were well compensated and there is less evidence that if they are not paid a regular amount of money, not necessarily a salary, it's difficult and, and, and we know that uh health ministries are very reluctant to put more people on their payroll so that that's a question that needs to be addressed, um. Intermit the quality versus quantity during the pandemic, I think it was a combination of both. I mean, it's, it was clearly at some point just quantity. Uh, we needed the number of vaccines at some point early on we needed the number of beds, but we know we also, um, needed the, for example, there, uh, when I was talking about equipment we know that even if we had beds we needed oxygen, so um. That's, uh, so it's a combination of both, but I as So a lot of discussion have been about, you know, um. No, I should clarify my question. OK, to clarify my question, Jamie. The Uh, you, you said that trust becomes a more important thing during a pandemic. And somewhere along the way, you also said that trust and quality are more highly correlated than trust and quantity. So that's why I was thinking that why aren't you connecting them and saying, well, a good way to prepare for pandemics is, of course, to increase the trust in the system, and the shorter cut to that is to increase the quality, because, you know, I could imagine somebody who, who does not have easy access to the system, uh, during normal times, might actually make an effort to actually access it. Uh, during a pandemic, but they won't make, but they won't make that effort if they didn't trust the system. Trust is we we can't hear you sorry, sorry, let me repeat independently of trust, investing in quality of health care is already important just given the number I've I've given from that that paper by Margaret Krookk and others then I think you're right. I mean investing in quality is the way to build trust, um. In the sense that, and I, I think also for example we are working with Aditya in in in East Asia on a report on the primacy of primary care. So basically the way you develop trust in a health system is having access to a regular primary care provider. You establish a relationship, you trust that person and then. When that person tells you, well, you should wear a mask or you should come and get vaccinated, you should come and you are 35 or 40, you should come for screening for diabetes or hypertension, the population are more likely to trust them. Um, So the Team, the so this interaction between uh pandemic preparedness and quality or strong health systems, uh, yeah, I think we should avoid that dichotomy. I, I see it coming around, uh, so it's I mean I, I think. Jet and Gabrielle, well, Gabriel is more skeptical, so. Um, I, I, I believe, I mean, I don't have a strong evidence. I, I provided evidence from, uh, that paper by Arseno and other, uh. COVID-19 vaccination rates were positively correlated with having a regular primary uh physician with trusting the health system, so I, I do believe that uh. That works hand in hand, uh, trust and quality and pandemic preparedness. I agree that we need, uh, other things, for example, one health. I'm not a specialist, but, uh, so I, I don't know the cost, cost effectiveness. Uh, I'm, I'm sorry, it seems that it could be also very cost effective. Also, I don't know how costly it is, for example, to uh acceptable it would be to cut every wet market in Asia. Uh, and I, I don't know how feasible it is, but um. But clearly in terms of surveillance, it should be feasible, including wastewater surveillance. So I, I guess I've touched a little bit each of your points, but not all of them. So we have a couple more minutes um. I want to give people online a chance. I, I think somebody raised their hand and then put it back down, but since we have a minute, if you have a, you know, a 32nd question, now's a good time. Otherwise, I do wanna ask Dina if she has any rejoinders to any of the questions or comments. Uh, do you wanna, do you have, OK, Dina. No, I mean, look, I think that this is asking the all the right questions, right, about, um, you know, how to prioritize and, and phase, uh, investments and, you know, throwing in one health is absolutely relevant and it's a big, uh, piece of the, um, work, uh, that's gone into the, um, the GCP with together with, uh, our ag colleagues, um, but we need, uh, to look at these questions of, uh, trade-offs and, and, and cost effectiveness and. I fully agree with Tim that this, you know, framing is really important and I see it tripping us up even in the conversations, uh, internally, um, uh, you know, are we putting, uh, I mean, I, I heard it, you know, from, from, uh, uh, important people in the institution. Are we, you know, um, uh, throwing our exit preparedness at the expense of, um. Uh, health system strengthening, UHC primary care, and I think we need to be able to map, you know, how these things reinforce each other and, um, you know, have some sort of a. Uh, a framework for, you know, prioritizing within, you know, uh, this, these two subsets that are really overlapping interventions. Um, so, I, I think you're asking the right questions and, and we need also, you know, uh, you rightly, uh, put it also in the context of the shifting burden of disease, right? And, uh, and, and, and we have a lot of different patterns going across, right? The, um, Uh, the, the, the regions and, and countries. So thanks for, uh, throwing these ideas out, and I, I think we need to, you know, follow up and, and, and sort of decompose some of these, uh, these questions, uh, further. Thanks. Thanks, Dina. Um, in a minute, I'll turn it over to you in one second, but just let me, in conclusion, from my perspective, say I, I really, this has been incredibly insightful, but also I've really enjoyed the sort of the research operations joint discussion that we've had in this session, you know, bringing together kind of all this evidence and research and then Both your experience but other people's experience in the room actually literally going going through the operational side during the pandemic but also sort of reflecting on it together afterwards. So I really thought that was great and and You know, as we think about the, the, the Global Challenge program, I think jointly thinking about how to sort of shape that and what that's gonna involve both on the operational, but as well as the knowledge agenda that's associated with that, I think this is the start of that conversation and certainly not the end. But, but in a minute, over to you to, to wrap us up. Uh, thanks everybody. Yeah, thank you, uh, Dion. Uh, I, so, so I wanted to go back to the the point that I started with, which was, you know, to try to sort of see whether or not during the pandemic, did we kind of get herded into saying the same things for all countries. And those things were basically the things that we were hearing. Um, the, the medical practitioners, as well as the public health officials and others, say for advanced economies, right? Uh, so, I thought that's an important question for Dina, because, uh, so as strategy for the next time around, I think it, it would be really important to actually see whether we would, um, do the same thing that we did the last time or not. That was one thing. The second thing, and, uh, uh, the, there, I thought it was very important to sort of look at these data that Damien presented, and he sort of showed, uh, he, he, he, he showed the excess mortality numbers being quite different, for example, especially for lack and ECCA. And that kind of surprised me because I would have thought that, I would have thought that those, those, uh, those were the two regions where the quality, at least, of the healthcare systems would have been better as compared to the others, but maybe I'm missing something. The point that, that I'm trying to sort of make is that, would there be region-specific uh pandemic strategies? So rather than think about this in a very global way, would it help us if we sort of thought about it for a subset of countries? And I think that, that, that you, you, you, you, you could sort of think about it as um Uh, by region, because that's a good proxy for quality or some other indicators of primary, secondary, tertiary healthcare. Or you could think about a better categorization of saying that, OK, you know, we're actually going to find this is the best indicator of uh how well prepared a country is for a pandemic. It's not the ones that we were looking at, you know. Um. And that's the, and that's the indicator then that we should really be targeting and trying to sort of improve. But those are my lay observations, and I'm, uh, so I will, uh, uh, leave the debate uh to the experts with, but I leave with, uh, still with a dissatisfaction in terms of whether or not we are actually learning the lessons of the pandemic. And I'm not just talking about the healthcare systems. I'm also talking about education. I'm also talking about social protection. I'm also talking about fiscal policy generally. And monetary responses. I'll stop that. Thanks everyone, and see you at our next policy research talk. Thank you. Thank you, Dion. Thank you for sharing so well.

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