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ISOBEL COLEMAN: Good afternoon. Good afternoon, everybody. If you don't mind, we're going to get going with the rest of our program while you're finishing your lunches.

As my colleague Laurie explained earlier, Congresswoman Betty McCollum could not be here with us this afternoon due to some pressing legislative priorities in Washington and we do apologize for that. But we are creative and we're going to fill in here at the Council on Foreign Relations. So thank you all for joining us. I'm Isobel Coleman, I'm a senior fellow here and I also direct the Council's Women and Foreign Policy program. And the format that we're going to follow this afternoon for this lunch is we're going to call it Oprah-light, I'm going to be the blonde Oprah -- (laughter) -- and I'm really going to walk around the room and call on some of you who I think have unique perspectives that we haven't fully heard from and fully discussed this morning on the very rich and varied conversation that we've already had.

Before launching into that, I just wanted to take a few minutes to not, not to try to put words into Congresswoman Betty McCollum's mouth, but to just summarize a couple key points from conversations that Laurie and I have had with her over the preceding months leading up to this conference, both in Washington in her office and yesterday after our session on Capital Hill. And she said a couple of things that I think are instructive and useful to hear.

One thing she commented on is just the very, and Laurie already alluded to this this morning, the very difficult political climate today in Washington for this particular topic. She mentioned, and we've had a lot of numbers bandied about today, there is a $10 billion number on the table to try to meet MDG 5, there's also $1 billion asked specifically for the U.S. government and Betty in her office expressed amazement at that figure in today's political climate and really relayed that she thought it was quite unrealistic. And I think, and this is from a friend, a friend of maternal health, so I think it's useful to keep in mind some of the political constraints and really think of ways to work with those allies on the Hill and co-op those who are not currently friends on this issue.

One thing that she said is she's blessed by having a constituency that is primarily Norwegian immigrants in Minneapolis -- (laughs) -- and they get through -- whether through their Lutheran background or from their immigrant status over the -- they get the whole notion of foreign aid, but she says a lot of her fellow Congressman, their constituents don't. And what she tries to do is walk in their shoes and to understand the issue and the constraints that they face and build a broader constituency and build some momentum for this issue.

So I think that's a very important issue to keep in mind. And something that I hope all of you here today will leave with the thought that there is a lot of momentum around this topic and this issue, but how do we build on that momentum, take it to the next level, and really make it a breakthrough issue over the next decade so that we're not five or ten years from now sitting here and having that very same conversation.

Dr. Allan Rosenfield is here and he wanted to just make a short comment because he has to leave. So I'm going to bring the mike over to him and then we will proceed after that.

Q(Inaudible) -- today.

QWe're not hearing you.

Q-- (inaudible) -- and if I just say some of us have got to convince Barak Obama to -- (inaudible) -- vice president -- (inaudible) -- secretary of state so he -- (inaudible) -- he beats McCain. And then we will probably try to get -- (inaudible) -- to take over USAID. (Laughter.) But maybe we'll -- (inaudible) -- global health.

But anyway, congratulations on a very good meeting. Sorry I have to leave a little early. I was very glad I was able to be here. Take care. Bye-bye.

(Applause.)

COLEMAN: Thank you, Allan. And all of us here really pay homage to you on this issue. You are the godfather of maternal health and has been a leader in this field for the last 40 years. So we thank you for coming here today and being with us. Thank you.

(Applause.)

Now, unfortunately my old friend Anika Rahman, she and I went to college together, leaned over to me during the lunch and said this conversation feels exactly the same as it did 15 years ago when you really started working in the field. And so what I'd like to do is ask Anika but also ask Jill Sheffield who's been working on this issue for a very long to, is this conversation today like it was 20 years ago and if so, if not, how is it different and in what ways that it is disappointingly similar, how can we change that? How were you thinking about taking this issue to the next level?

QThat is the perfect question -- perfect question because we're the really new place in this entire arena and I really confess -- I had lots of confessions, but the one I'll make here is that it's MDG 5 that I really care passionately about and a whole lot of people have worked for a long time. And the truth is we've made a tremendous amount of progress. It may not look it in the numbers, but there are countries, low-resource countries, who have halved maternal mortality in less than a decade. And there are lessons there to be learned and we're very busy learning those.

We've come together about what it takes to reduce maternal mortality. We know what it costs and we know what it costs not to do it, that's the tragic part.

I think we've agreed on free pillars and a group is adding a fourth which is post-partum, post-natal, I get the words wrong, it's after the birth, and it's for both mother and newborns, so it's reproductive health service and family planning, it's skilled providers, it's emergency obstetric care, and the last one is making sure those women who delivered come back for care because those deaths tend to happen in the 24, 48 hours around delivery.

So we've identified capacity. The three things that Nils was talking about knowledge, I think we've made a lot of important progress. Capacity at least the -- (inaudible) -- we can identify is that we know what we have to do in capacity building.

The place where we have absolutely not made progress is on the advocacy fund. It's the hearts and minds of those people who make decisions about policies and about money. And today we heard that we need civil society involvement big time. That's undoubtedly true. But I'm beginning to think we need a major mind shift about why those lives are worth saving. I was just saying to Sheila that I wish people cared about saving women's lives because they're important lives to save. Apparently that's not so, so we need to find the reasons why they really are important. And I think those are economic reasons.

Did you know that every year the impact of maternal mortality costs our world $15 billion in lost productivity? So with the $5 billion that is the ask for making major reductions in maternal mortality and new born mortality and that's the half of the $10 billion because the other half is for children, saving those lives, you could get a times return on your investments. What other money market is going to produce that? (Laughter.) So I think that where we have to put the effort are only arguments that make the most difference and the most sense to those people who make policy decisions. And we need everybody's help in doing that.

So when you get good ideas don't keep them a secret.

COLEMAN: Thank you.

Anika, you were on the frontline as the head of UNFPA, Americans for UNFPA, of talking to people grassroots organizations, people in civil society, to try to drum up support, American support for UNFPA, and for those of you who don't know, Americans for UNFPA was created after the United States decided to withholding funding for UNFPA to replace that money through private donations, private individuals. So maybe you can tell us a little bit some of the arguments that you used for trying to convince Americans who may not be aware of the issues, who actually may be even hostile to the issues of why they should support UNFPA.

QWell, I approach that a little differently and I don't usually disagree with Jill. The reason I think that we have been somewhat discussing the same issue for the last 15 years is because there's an internal community, we're the converted, we believe in these issues for different reasons. But when you try to reach out and build a broader constituency, you come head on with the fact that most people don't know these problems and you have to appeal to different social movements and different sentiments that people have.

The list of choices that I find that I think both globally that exist and that certainly exist in a donor country like the U.S. are is how you frame the issue of whether, of maternal health. I deal with probably a menu of four options here, and you will probably pick and choose ala carte and blend them.

But the four options really are, the first one is women's rights of equality, sometimes it appeals to some audiences and not to all, you can imagine that. The second one is economic development -- (inaudible) -- reduction argument. The third one is environmental. And the fourth one I put in a separate category in a way because it has a long history is what I would call population stabilization. Now, that can link up to all of the above three so these are not disparate ways of looking at things, but these have been the four strands that you can pick and choose when you talk about building an external constituency for these issues, not really talking about this room as such.

And I think that the arguments you will favor over time will depend on the political environment that you're dealing with and your target audience. So I'm not going to say that how you deal with a Norwegian audience or a Bangladesh audience is the same as when you're trying to build a constituency for these issues in the United States. But I do think that this mixture of four is what you're looking at globally. And then we you talk about your target audience, if you want to build a constituency from maternal health and you're starting in the United States, your natural group is women. But how do you reach out, this is a country of 300 million people, 50 states, vast, expensive to operate in. And you would have to go for your lowest hanging fruit which would be women, but women don't always agree with all of these issues.

You also are dealing in the United States with one of the most successful environments -- social movements being the environmental movements, so how do you engage them? They don't -- (inaudible) -- need us. They see our issues as being difficult for them. So why would they engage us? They have a vast constituency. Ours is not that strong. And unfortunately maternal health in the United States is viewed as a partisan issue. Very linked to Democratic politics. We have failed to make it a bipartisan issue. It must be one. Because the issue of maternal death is not just about Democrats, it's about the world and every woman.

These are the challenges and I don't know if that's enough of a frame setting but I do think that also once you decide which of these four frame setting or which elements of each you will take, the issue becomes what aspects of maternal health do you want to focus on? Obviously issues like -- (inaudible) -- are much more sympathetic on one end and the issue of abortion is the most divisive.

Thank you.

COLEMAN: No, I'm coming your way. The billion dollar ask, I mentioned in the beginning Betty McCollum's roll of the eyes over this number, you, I've heard you say over the last couple of days now repeated several times that who would have thought ten years ago that we would have seen the increases in global health spending that the United States is committed to that we now enjoy. So your glass is half full, you're optimistic, how do we get from where we are today to that billion dollar number?

QWell I should first of all note that that billion dollar number from our standpoint is an interim number.

COLEMAN: Yes.

QThat's where --

COLEMAN: On a way to a larger number.

QOn a way to a larger number.

COLEMAN: Yeah.

QNow, I think the challenges of, I won't get into this inside baseball of Washington budget allocations, that's for another time and another audience, but I think the key question is generating a big enough political constituency in Washington, which comes from both advocacy at the grassroots level, as Anika was talking about, and also sort of the inside lobbying that takes place sometimes very effectively in the halls of Washington for the key issues. And clearly there's a strong constituency for children's health, that can be mobilized. There is you know, there's a more polarized constituency for women's health and for family planning, but it's a polarization which at this moment works very much in favor of the forces that are in this room. This is a movement that's on the ascendancy at this point.

So you can get to a tipping point fairly dramatically. Do I expect it to happen between now and November 5th? No. On the other hand, I also expect that we're going to have a continuing budget resolution, sort of a continuation of last year's spending, going up through this coming elections because nobody basically in Washington wants to give the president a bill that he'll veto. They just want to sort of keep things going until they see who the next president's going to be.

So I see the possibility of keying up something which would be ready because this year's budget is supposed to be passed by September 30th, our fiscal years starts on October 1st, hasn't been for years, and they do a continuing resolution, another continuing resolution, usually into the new calendar year and then Congress usually passes an omnibus bill. Let's say Congress passes the 2009 spending bill in an omnibus bill on, oh, let's say January 21st, 2009, that would not be subject to the same veto threats that it would be on January 19th.

So that's what I see is the potential dynamic for a billion dollar ask, that it sort of gets into the political discourse, it's sort of held in the back pocket, but then it gets moved.

QThis is Laurie. You can't see me, I just want to bounce off what both of you just -- actually all three of you just said and make a suggestion.

If the maternal health advocacy community is seen as waiting on tender hooks for Obama to be elected, and is seen as only speaking to that party, and to the expectations of that candidacy, it will fail. John McCain should be hearing from you just as much as Barak Obama, if not more. And the second piece of that is a real quick anecdote.

Back in the very beginning of our HIV/AIDS epidemic, Ronald Reagan appointed a man as surgeon general who made a movie, which was the basis of being appointed surgeon general, in which he stood next to the ovens of Auschwitz which he had filled with baby dolls and likened abortion to the Holocaust. This man came in as surgeon general as probably the biggest foe it seemed imaginable. When he saw babies dying of HIV/AIDS right across the river here in Newark, shown it by a Roman Catholic physician who wanted him to see the suffering these babies were going through, C. Everett Koop had a moment of conversion. And he came away from that with a totally different attitude about abortion, about family planning, and about the appropriate intervention.

And I say that because we are already hearing from many of the former anti-family planning voices in both the Democratic Party, and let's not forget there's a large constituency within the Democratic Party leadership that is opposed to family planning interventions overseas. But from both parties we're hearing wait a second, how can we keep funding this HIV treatment cycle if for every two people we get on treatment, five more are infected? What's our end game here? Is this an entitlement program for the United States government to endlessly fund HIV treatment overseas if we don't allow condom distribution, if we don't intervene on the prevention side we have a non-sustainable long term program.

This is a window of opportunity on both sides of the aisle that people should be walking into that this moment.

COLEMAN: Thank you.

Gab Gordis (ph), I'm walking over towards you. CARE has been a very important supporter and partner of ours, the Council on Foreign Relations, in putting together this program. And it's also made maternal health one of your leading initiatives and I wonder if you could just give us a brief comment on how CARE is thinking about maternal health and about mobilizing support both in Washington and more broadly among your grassroots supporters for the maternal health issue.

QThank you, Isobel. And I want to thank CFR for taking this issue on. It's so important for us to broaden the constituency working on this issue and to incorporate new advocates and partners who can speak in different languages to the folks that we need to be speaking to which include economists and bankers and disciplines that public health geeks such as myself are not as comfortable speaking to.

CARE has taken on the maternal health issue as a signature program very much embedded in its empowerment of women approach. And I just want to address a couple of issues that came up in the morning sessions from the programmatic standpoint.

Advocacy is a big strand, is a key strand of our maternal health program at both the global and the country level. And it's I think important for those of us who are thinking more globally and looking at the big picture and funding to remember that there isn't a one size fits all approach that we are going to be working in settings that vary tremendously. The infrastructure varies, the level of relative devastation of the health system varies quite a bit.

I know from work that I had been involved in at my old job with the American College of Nurse/Midwives in Liberia that ministry of health is taking on working at both the community and the facility level to implement that full continuum of care despite the fact that they have lost so many of their health workers.

And we need to avoid this tendency to dichotomize what we're trying to do between low tech and high tech and community and facility because we all know in this room that it is a chain and all elements of the chain have to be supported including the global advocacy and the national advocacy.

And in the countries that we're going to be working as far as the approach we need to take with the GA and so forth, we're not starting from scratch. And I think what civil society and NGOs that this CARE can do best is work within those systems to look at what the gaps are, you know, where are the problem areas in that particular setting. And figure out how we can build partnerships to address those gaps and strengthen what's there. And that way, attract more people and more donors and more opportunities to build a fully integrated health care system within those settings and under the leadership of those countries.

So this requires a lot of partnership and a lot of very, very creative and economy-efficient thinking and planning.

I also wanted just to make a comment about the wider development issues in education and literacy that came up earlier. They're very, very connected and a lot of the countries that we work in part of the work force issue is that there aren't enough girls coming out of secondary school to fill the places in nursing and midwifery school. And midwives are the front line health care providers in developing countries, particularly in rural settings and there was a lot of discussion about that, how difficult it is to get doctors into those rural settings and we need to continue as we look at the full development picture, think in terms of girl's empowerment and girl's development and girl's education because they are not only the number one producers in agriculture in all these other areas that we know that women are so incredibly productive in, but they're critical to rebuilding these health systems.

Thank you.

COLEMAN: Thank you, Gab.

When Judith Housener (ph) came to Laurie and me almost a year ago now, last summer, and asked us to take up this issue of maternal health based on a conference that we had done a year before that, you know, Laurie and I were both really excited, because it is such a natural intersection for the work that we do here at the Council on Foreign Relations. Without, at the risk of putting words in Laurie's mouth, I think maternal health is really a critical marker as we fall into discussing of a global health system. You know, if you can actually save women from dying in child birth, it's a sign of the health of the whole global health system.

And for me, you know, when you look at the work that I do here, which is trying to really elevate the status of women as a foreign policy issue, and draw that connection to the economic drivers, to the political drivers, to the security drivers, women's empowerment can best be measured by whether or not countries allow women to die in childbirth. It's just such a natural marker for both of our programs.

And so it was with great enthusiasm that we took this up and we're thrilled that we could all be here today at the culmination of this. But I'd love to hear now from Judith as a funder of this particular issue that, and from MacArthur's perspective how you're thinking about taking maternal health to the next level, what are the levers that you're looking at, what are the driver's that you're hoping to achieve?

QThank you. If you don't mind, I'm going to stand up because I'm going to waive some materials around, too. They're in your packets by the way, you don't have to pull them out now but I just want to highlight them for you. Thank you very much Isobel and Laurie for taking this subject on. Yesterday Neil said, and I'm sorry I came in late today, so I don't know if he said it again today, that 10 years ago he was asked what would be an indicator of global health really gaining prominence in U.S. foreign policy and he said if the Council on Foreign Relations would take it on. (Laughter.) So of course Laurie's here as the senior fellow on global health. Isobel and Laurie have agreed to coordinate on the maternal health scene and we're very delighted about that.

For those of you who aren't familiar with MacArthur as a donor in maternal health, I thought I would give you my two minute spiel, my two minute description of what our program is about, if that's all right. The population and reproductive health area of MacArthur has only about $13 million a year and we work in three countries and they're important and large countries, India, Nigeria, and Mexico. We actually have offices and staff in those countries, and about 70 percent of the $13 million is actually allocated to work in those countries. So most of our program is very, very country specific.

And one of the things that we pride ourselves on and that relates to the question of whether our priorities and our levers for change is working in those countries with these amazing staff who have contacts, connections, overviews, who know the political lever in their countries, and supporting a lot of local NGOs so that we jump through all of the what they call expenditure responsibility hoops that make it a little bit harder for U.S. private foundations to fund non-U.S. 501(c)(3) groups, but we make a big point of doing that and we're giving not just funding but assistance in monitoring and evaluation, assistance in strategizing about scaling up the models that these NGOs are doing.

And we have some amazing successes in India especially of some of the NGO grants that were started with our funds that have been or are in the process of being scaled up with government funds or other donor funds. One of the consequences of spending 70 percent of our funding in those three priority countries is that there's only 30 percent left for everything else that we do. And that includes two themes, we actually work both on maternal health and on young people's sexual and reproductive health and rights. So this is a newsletter that talks about both of the two themes, some projects from each country and from the non-country specific work. And this is just kind of a little briefing sheet on our maternal mortality work including some examples of projects that have been funded in the last few years.

And the way that we look at the cross-cutting portfolio is that while we're already devoting 70 percent of our little tiny portion of MacArthur funding to maternal health and youth, hmm, that four million is very, very precious, we do a lot of different things with this. Some of it is for maternal health and youth, and the support to the Council on Foreign Relations cuts out of that cross cutting portfolio.

Some of you are familiar, I think, with the research that Jeremy Shiffman (ph) did on generating political will for maternal mortality, and that was a grant of ours that also came out of the non-country specific cross-cutting portfolio, which was focused on India, Nigeria, and the global community of most of you, many of you sitting here.

Because McArthur is relatively small, and because those countries that we're working in are so huge, we have chosen -- not exclusively -- but we've chosen to focus on a couple of key causes of death. So post-partum hemorrhage is the largest cause of death when you look at the breakdown worldwide, and especially in Africa and Asia, and so we're focusing a lot on that, including some interventions that recent research has shown to be effective. Oral misoprosotol, given prophylactically to every woman right after birth, has been shown to prevent 50 percent of births in a randomized controlled trial in India with very low resource settings and relatively low skilled auxiliary nurse-midwives giving the drug.

The so-called anti-shock garment, kind of a lower body suit, which is kind of a temporary, stabilizing, big giant band-aid for a woman who is experiencing post-partum hemorrhage, that can stabilize her and keep her from dying for up to two days, which gives time for overcoming those three delays that we all know about; the delay of recognizing the problem, the delay of transporting the woman with a hemorrhage in this case to a facility that has skilled care; and the delay in getting definitive treatments such as blood transfusions or surgery or whatever once she's there.

So we have chosen to invest in post-partum hemorrhage and in eclampsia, and Gender Health is one of the grantees. Genuity is another working on our relatively few grants. Really it's just two grants so far on eclampsia. That happens to be a higher cause of death in Mexico than hemorrhages.

So, you know, we understand completely the need to change health systems. The experience that we're seeing on the ground with our grantees working on these things is that you really can't work on training people and having the systems in place to use the anti-shock garment, or magnesium sulfate for eclampsia, without somehow improving the health system. So we see these as wedge issues where you start with one particular quick win, and eventually things have to change. The upgrade of facilities has to happen and people have to be there and better trained. So, you know, we are thinking that there are ways for at least us as a donor to both try for some of these high-impact quick wins, and at least indirectly work with others as partners to improve the health system. Thanks, Isabelle.

COLEMAN: Thank you, Judith. Brian, I wonder if I can call on you now and ask you to talk a little bit about the private sector, and the role that the private sector can play in both mobilizing support at a grassroots level, and then politically, and also economically providing resources to drive this issue of maternal health.

QUESTIONER: Thanks, Isabelle. You know, the private sector traditionally has not been engaged in health issues.

COLEMAN: Right.

QUESTIONER: But there is a new climate of corporate social responsibility, which is focusing on sustainable development, the way you do business, wherever it may be. How are you contributing to the long-term? And a lot of the current investment is certainly around environment and climate change. I'm working very hard to try to get health up there alongside of environment as another global issue, which is particularly important for business, because in the end, we're all looking for new markets, and the biggest markets are the emerging markets. Lots of people there, and that really is going to be a big future, and if those emerging markets are burdened by disease, they're not going to be good for business. So I think for business to take a long-term look, and to say it does make sense to understand health issues, and begin to invest in health, that's another good leg to the whole sustainable development theme that is becoming an important part of the way you do business.

And then once you've adopted health, then to start within that, to say, well, what particular aspect of that are we going to tackle? And I think you're going to get good guidance from the MDGs if you want to pick up areas where you want to start, so clearly the communicable diseases -- HIV, AIDS, TB and malaria -- is one big area, and then maternal mortality is another huge area. But, in fact, you're really talking about women's health.

And more and more, we are seeing that none of these problems are going to be solved unless we strengthen the health systems. That's really what we have to do, and that's a long-term thing that the world is just going to have to get busy with, and needing to understand exactly what those interventions are that we can put in place that will help.

And it is a long haul to get business interested. I work for a mining company. We have 75,000 employees in Southern Africa, and we experience these problems firsthand. And we've realized certainly in the workplace that the investment that we make in the health of our employees, the return on that investment we get many times over. But we've also realized that unless we take that same investment beyond the employee, and if we don't go to the families as well, we don't actually create a sustainable response. So we are moving from workplace to community, and I would just hope that we can get many other businesses to start working the same way, and it's beginning to happen, but it's slow.

COLEMAN: And Anglo-American has really been a leader in this whole trend of getting the private sector and getting business involved, and making -- seeing the economic connection between a healthy workforce and the bottom line. Do you see other companies, other global multi-national companies like Anglo, getting it?

QUESTIONER: Certainly those that have businesses in developing countries, I think, are getting it because they see the impact on their workforce. They see it in their production, and they understand the value of that investment. I'm concerned that other businesses that don't have their production in those developing countries but do sell into those emerging markets don't see it, don't see the benefit of that investment in health. And I've spent a lot of time trying to encourage those businesses to recognize that, and I think we're just going to have to try to elevate the whole issue on the sustainable development agenda and the corporate social investment agenda. It's a long haul, but it's worth it.

COLEMAN: Thank you.

QUESTIONER: (Off-mike.) This is -- (inaudible) -- from BD. I just wanted to comment on private sector involvement. About 10 years ago, BD mobilized a private/public partnership with UNICEF to eliminate maternal neo-natal tetanus, a disease that kills silently both mothers and children, and this could have been eliminated by a simple tetanus vaccination, and several companies in the private sector jumped on board, even ten years ago. There was Boeing, McDonald's, and more recently I believe, Proctor & Gamble have joined this commitment with UNICEF.

And what I find missing in this room is a representative from UNICEF, because maternal issue is also linked to a child's issue, and perhaps that would be a good partner to involve and engage in this discussion as well.

But also, can you indulge me with a comment or a question? I couldn't get across to the panel one. I think when Laurie showed this world map or diagram, I was saying you could replace that disease with any disease in the world and the map of India wouldn't change, or it would be more or less the same maybe, and the question about, well, why does India need grants, and why can't they sustain on their own is a very powerful one. I visit India four times a year, and every time I visit I see new wealth and new middle class and new money, and the same poverty, maybe, in many parts.

And the question is what are we doing from a global diplomacy point of view, particular to India, in initiating a dialogue for them to step up their own, and there's this billion dollar asset on the table -- does that include commitment from India as well?

COLEMAN: Nils, do you -- okay, Sheila, you want to answer that?

QUESTIONER: Yeah, I wanted to add something about private sector, to say that in Botswana, you know, I'm sure you are all aware that we have one of the most successful HIV prevention treatment programs probably in Africa. It was started -- our pilot actually became our diamond mining company, DBS Botswana, which is Debswana. They started immediately after that conference -- Vancouver -- the one where we had hoped -- but the rest of us didn't really believe we had hope. They started a treaty in their own employees and their families.

And as a government we're then able to see what kind of successes, what kind of programs we are having, so that when we then rolled it out to the rest of the country we were able in a few years to be able to cover more than 90 percent of the people who need ARBs. And because of them, because we also -- you know, they were really looking at all the aspects of treatment, we have seen mother-to-child transmission in the country drop from 40 percent to less than 3 percent. So we've really been able to work with the private sector on that aspect.

COLEMAN: Thank you. Did you want to comment?

QUESTIONER: Just -- this is Anne Stars from Family Care International, and I just wanted to address the question about whether India is included in the Ask figure. The 10 billion (dollars) figure that I referred to briefly, which is 10 billion (dollars) for maternal, newborn, and child health combined, which was issued by the Partnership for Maternal, Newborn, and Child Health and is being picked up by various civil society groups.

And then FCI, which focuses on maternal health and a number of other maternal health advocacy groups, are lobbying specifically for half of that, for 5 billion (dollars), to be targeted specifically for the maternal health interventions. The situation right now is that global MNCH aid is split about two-thirds or more for child health and then about one-third roughly for maternal and newborn. So we'd like to see the overall pie increase dramatically -- I want to emphasize that -- and then the target is to have $5 billion specifically for maternal and newborn health. But to answer your question, India and China are not included in that Ask, specifically.

COLEMAN: Thank you. I'm going to open up to the floor for questions in just a minute, but before I do, I want to call on one last person, which is Maryellen Stanton, who we heard a little bit from earlier. But I think it's important to circle back around and hear again from USAID. The United States -- we've heard from a number of different people here this morning -- poses a number of challenges to this issue internationally, but it also -- traditionally has been a leader, and is the most important funder, the biggest funder in the world, and having the United States as an ally in this issue is so critical.

Maryellen, I know that you work with a lot of different political constraints, but maybe you could just tell us a bit more about how USAID navigates this issue, and how it's thinking about incorporating maternal health into some of the other very big funding streams, in particular PEPFAR, which has the lion's share of the funding right now from a health perspective.

QUESTIONER: Thank you. Yes, I think in working in a big bureaucracy with a lot of constraints and laws and regulations, particularly earmarks, inability to do basket funding, not enough overall funding and constraints on which partners we can send money to, it looks like, oh, gee, it's all problems. But there really are opportunities out there for those who have built their careers on working the system. (Laughter.) We have a big opportunity with this funding that's in infectious diseases -- in HIV and in malaria, for example. There is some talk about wraparounds and how to use the money.

When I was out in Africa a couple months ago, we talked with our mission personnel, and they are very creatively working, I think, with some of the PEPFAR funds and the malaria funds. There's a real intersection. Are these programs going to start from scratch, or are they going to build on a platform of maternal child health that is already there -- not nearly as good as it can be, but with that funding it can become stronger. So as PEPFAR reaches its own goals it can shore up work in maternal health for providing resources for training providers, for upgraded facilities.

Now, everybody has different views on how to view those rules and everything, but the thing is, you can't control everybody, and I think people are looking at the situation in the countries. We've been told so often every country is different, and we're really trying to work with the government health plans, whether it's a reproductive health plan or a safe motherhood strategy, and with the resources that are there, in order to pull this money together where we can for good pregnancy outcome. So I think there really actually is hope within all these constraints that we can make better use of the funds out there, for bettering the lives of women and getting their survival.

COLEMAN: Thank you. Brian's got another comment here, and then I'm going to take questions.

QUESTIONER: I'm sorry, just as a follow-up, I mean, I really would just like to testify to the magnificent work done by the USAID mission people, by the PEPFAR people, by the CDC people in-country. It really is extraordinary, and they're our closest allies in getting things done, and if ever you want quickly to get money, that's the place you go or ask, because you know they're people who will understand, and people who will deliver. I just wish that you could take the shackles off those professional people who know what to do, and leave the judgment to them, to decide what are the most appropriate things to do in-country. And I think the U.S. would get an even better reputation if you just allowed the professionals to do the job.

MR. : Yes, we can. (Laughter.)

COLEMAN: Yesterday we had the country director from Tanzania at our meeting on the hill, Charles --

MS. : Charles Llewellyn, the health officer.

COLEMAN: -- Llewellyn, the health officer, and the figures he gave were quite astounding for Tanzania -- $300 million for HIV -- and he was so proud he had doubled maternal health to $5 million, and he had doubled it. But he understands those constraints. It's not like these guys are stupid. They totally understand what they're up against, but they're very real constraints that they're trying to work within creatively.

QUESTIONER: Yeah, I just wanted to point something out. I know I keep going to this map, but I really think it's very useful to look at it. You know, China's almost non-visible on this map, and Ranuca (ph) brought up India and asked about pressure on India, and I just want to be very, very clear. When we talk about the MDGs, we previously talked about the distortion impact you would have by just trying to achieve your MDGs through urban center change.

But similarly, the fact that China isn't on this map doesn't mean China has a great health system. I've spent a fair amount of time in China. It has one of the worth health systems on the planet. It's not on this map because it has a one child policy, so the statistical probability of any given women dying in childbirth is vastly decreased, because she's pregnant once. India, in contrast, has one of the highest fertility rates on the planet. So again, I just put that forward to say let's be very careful about how we talk about health systems and how we talk about the MDG related to maternal mortality, because there are massive distortion effects that are a result of separate policies.

COLEMAN: Just one more comment on India. India is a country with hugely disparate fertility rates. So Kerala province, for example, has near replacement level fertility, whereas Rajasthan has one of the highest rates in the world, and it is straight-line correlation with girls' literacy. There is 100 percent female literacy in Kerala and there's 20 percent literacy in Rajasthan. It is straight-line correlation between fertility, maternal mortality, and illiteracy. And actually, somebody said to me, oh, maternal mortality? Just put girls in school. That's the way to solve it. I'm not saying that that is the answer, but there is a very, very strong relationship between the low status of females in society and this particular issue.

I'd love to spend the rest of our time today just hearing questions from all of you. Kay, we can start over here.

QUESTIONER: Yes, I'm Kay Bora Miller (ph). I'm an attorney at Merck, and I have a question, well, a request to those -- the multiple experts in the room, to address the issue of improving maternal health within the context of very troubling circumstances and -- circumstances that are really exigencies in countries and communities. For example, it was mentioned -- the sex industry on the Indian subcontinent, and you know, the hundreds of girls and young women who are driven into this industry, and the physical vulnerabilities that can come from that. On the continent of Africa, there are countries and communities where there is a continued incidence of female circumcision and cutting, and it as also mentioned armed conflict, and we hear reports, primarily from the Democratic Republic of Congo, where there are numerous assaults and violent rapes against women by soldiers who are fighting there.

So the question is, are these exigencies competing with the overall improvement of maternal health? Do they impede it, obviously, or does it fall within the general umbrella of maternal health? Because some would argue that there are priorities -- it's a question of priorities.

COLEMAN: Well, I think the answer is yes, yes and yes to all of those. Sandra's here from the Women's Commission, and maybe you would like to talk just a little bit in answer to this question about women in conflict and conflict situations and refugees.

QUESTIONER: Sure, thanks very much. Yes, yes and yes. Globally, there are 35 million people in the world who are displaced by conflict and civil strife, and we've made every effort we can to address the sexual and reproductive health issues, to advocate that they're on the agenda for these populations in particular. One recent initiative we've undertaken -- and this is kind of built on some of the ideas that have been brought up so far -- because I think we need to start talking to different groups. That's been brought up by various people, whether it's, you know, industry or environmental folks or whomever. So one of the recent efforts we've undertaken with PATH -- for those of you who don't know who PATH is, it's a longstanding appropriate technologies group -- to look at bringing underutilized existing technologies into the field of humanitarian response, and also looking at the new technologies, such as were brought up earlier here.

And it was very interesting. We hosted a consultation on new technologies in sexual and reproductive health at PATH just last month, and brought in actors who are experts in reproductive health, who are experts in response, and who are experts in these new technologies, and it was very, very interesting to just start talking to different people about what could be done, because I think that's what we have to do. We have to work kind of with what's out there as well, you know, in terms of all of these issues, and start talking to different groups about how to make it happen, instead of our same, you know, partners in development or emergency response or technology. So we're really looking forward to moving that agenda forward, new technologies in these settings. And those are, you know, the mesoproxyl, possibly the anti-shock garment, that kind of thing.

COLEMAN: The unintended consequences, too, of technology -- there's different solar-powered cookers that are now being made available to women in refugee camps that can mitigate their need to have to go out and find firewood, and it's when they're going out to find firewood that they're raped, that they get pregnant, and that they then become victims of maternal mortality. Again, it's this whole continuum of issues that all seem to go together.

Over here.

QUESTIONER: My name is Joseph Ruminjo. I'm with the Engender Help Fistula Care Project, and we've had a gratifying collaboration with USAID, with UNFPA and other esteemed organizations and foundations. And I want to address the issue of wedge issues actually -- as was mentioned, such as, you know, post-partum hemorrhage, eclampsia and so on. And it's unfortunate that sometimes we get inured to facts and figures related to women dying in pregnancy. You know, the -- (inaudible) -- minister from Liberia mentioned more than 1,000 women per, you know, 1,000 live births, you know, almost unbelievable figures, you know. But they happen, and we look at them and move on to the next thing, very unfortunately, but because those women are dead.

One issue that's a little different is the issue of women living with fistula, obstetric fistula, and it's different in that, well, those women are not dead, those women can tell their story, and their women are what was referred to earlier as a prism reflecting a failure in our maternal health systems. They are really useful. There are more than 2 million women living with this problem, and the treatment issues, you know, we can deal with, but the prevention issues are very, very similar to what we are talking about, preventing death. So we can use a wedge issue like that to address not only prevention of fistula, but prevention of maternal death. All the delays that we were reminded of at facility level in transfer the women to a facility at facility level can be dealt with that way.

My second last reference is to the -- what was mentioned in the first panel about the siphoning of skilled personnel outside the developing countries to more developed countries, and it's -- well, for sure it's a huge issue not only for doctors, but paramedics especially, midwives, and Allan Rosenfeld reminded us that task shifting in some countries such as Mozambique, Tanzania, Malawi even has addressed some of that issue.

However, you still do need these skilled people in some facilities, and my question is -- I didn't learn this from the first panel -- what is being done in collaboration between the developed countries and developing countries to improve the working environment, the policy, the management and material support for these skilled workers in their own countries so they don't feel tempted to leave their working environment?

COLEMAN: Sheila, I know you've spoken a lot about this issue.

QUESTIONER: I talked about that, but I also did mention that I'm part of what we call a Global Health Worker Migration Advisory Council. (Inaudible) -- a council that advises WHO. Right now we are looking at -- it's made up of people from -- I think most countries are represented in that council. But right now we're coming up with a document because this has been a debate at various world health assemblies -- you know, between ministers from developed to developing countries, and it's always been a blame-blame situation.

So now it was like -- well, I think we've heard enough. Now let's sit down and see what we can do about it, because, you know, they'll talk about it, you know, these ones will be in the developed countries. And people like us in Botswana -- we are caught in the middle, because we are a giving country, but we're also a receiving country. So it took people like us who say, look guys, let's sit down and really say why do you think that can be done in terms of training, in terms of retention and how we can collaborate on that one?

So various things are coming up, such as sponsoring, you know, people from developed countries, to come and study in developed -- from developed countries to studying in developing countries because sometimes the facilities are there. It's really the personnel. So we're looking at how you can then make sure that the trainers are there, whether they are from developed or developing countries, and just to produce enough that one day -- we don't know when -- we'll no longer be fighting about people.

Because there's no way you can prevent people from moving, and it doesn't matter how much retention you put in. Granted, you'll -- (audio break) -- who won't want to go, but some people want to go just out of fun. You know, I may be in Botswana. I've never left Botswana, and I feel like I want to go and see what New York is like. So the next, you know, recruiter who is coming -- I'm hopping on. I don't care how much I'm going to get. It may even be less than what I'm getting at home.

But the point is, people move for various reasons. As a minister, I've had people moving because they were escaping an arranged marriage, not because of anything else. So that it's really then to say how then do we ensure that, you know, as few people as possible move, but also how do we collaborate between developed and developing countries to ensure that we have enough human resources for all of us.

COLEMAN: (Off mike.)

QUESTIONER: I just keep liking to -- like to point out as issues come up ways that we can build new kinds of coalitions and things politically about repercussions. Two points -- first of all, one issue that it would be very helpful if the maternal health movement glommed onto is the whole question in U.S. funding of overhead -- allowable overhead that can go to the local infrastructure that is greatly restricted currently. And what that means is you may have a very well-trained healthcare worker -- we were recently in Bangladesh and observed a setting where there was an extremely well-trained set of healthcare workers and they were trying to do deliveries in a facility that I don't even want to describe because you just ate lunch. So of course they're utterly demoralized.

So the first piece is to start to attack that piece of -- set of restrictions that are in our foreign policy funding guidelines from the U.S budget that limit our ability to fund appropriate infrastructure to improve the setting of the healthcare workers.

And the second is I think that the maternal health movement is a logical movement to build alliances related to our domestic healthcare worker force in the United States and the disincentives that have been put in place that make it very difficult to adequately train up domestic health work force, particularly nurses. And anybody that's really interested in pursuing this, the American Nursing Association on their website has a breakdown on why we are unable to train sufficient nurses in the United States domestically and therefore poach healthcare workers from foreign countries. And it boils down to 1,000 tenured faculty positions in nursing schools. That's it. Okay, that's not a big budget line. Linking those two would be a big plus for all sides.

COLEMAN: Maryellen, do you want to comment?

QUESTIONER: Let me follow up on what she just said.

COLEMAN: Okay.

QUESTIONER: In terms of infrastructure -- because there is that restriction -- and in Botswana, we are lucky enough to be working with U.S. ambassadors -- I mean, one of them I went to school with. So, you know, he would say, well, we will not fund infrastructure but at some point you need -- you have a small pharmacy. And you are saying -- for us to be able to save women better, we need this pharmacy expanded.

But U.S. funding will not fund that except if it's renovating a place. So what I then did, I went and said to people break it down and leave one wall. (Laughter.) (Inaudible) -- dilapidated. We need funding to do it -- and that we got. But, you know, I mean, it means going through a lot of that. (Laughter.) And we had to get help from the European Command.

And -- but so you learn to go around a lot of these but definitely that's very much one that's needed -- that will help in infrastructure.

COLEMAN: Maryellen, do you want to make a short comment just on this specific point?

QUESTIONER: Yes, I'm improving the --

COLEMAN: Supporting issue.

QUESTIONER: The new infrastructure -- this is not an absolute. Like any bureaucracy we've got waivers and we actually have used them. We've done a lot of infrastructure development in Afghanistan where you can break open and change the thinking, then we can take it to other countries. I know of nothing that says that we cannot upgrade. And we are doing that. I think we can do more of it.

I also feel there's a shift in thinking about infrastructure that is going to make this more possible. What we don't want to do is go back to what we did 30 years ago and build huge high-rise hospitals without plans for staffing for maintenance and so forth. So we've got to do this smarter than we did it before.

COLEMAN: Thank you.

Okay, I see a lot of hands up here. And I don't think we're going to be able to get to all of them, but let's -- if you can try to keep it short, we'll try to get in as many as possible here.

QUESTIONER: (Inaudible) -- from the Fistula Foundation.

I just returned back from Ethiopia about a month ago -- we just opened another hospital in Hadar. We're trying to build about five hospitals -- this is the number four.

The thing, though, I think when you're here, you feel very good about that this is the number four. But when you go there and you look at the numbers, it's actually very discouraging. I think after we build this four and we are adding one more next year, five, I think the total capacity is probably going to be about 4,000 surgeries a year except we have incidences of about 10,000. So we're going to be falling behind. So the issue about infrastructure, training, and prevention is actually key. And when we talk about things, in terms of Ethiopia, training, non-doctor doctors and infrastructure are really linked because it's a very mountainous region; there are not a lot of roads. I think the average person has to walk like 25 to 30 miles before they can get into a road. So when a woman is pregnant, even if you build some hospitals and big hospitals infrastructure, I think it's going to be very difficult for them to get to the hospital.

So actually the training about this non-doctors doctors who are probably going to be very senior members of their community and have them stay in their community and build these local committee clinics seems to be -- I'm not, you know, in the area of health, I'm just -- we raise money here for the hospitals in Ethiopia -- but I think that seems to be probably the logical way to go.

But as I was asking Paul earlier, I think it is recognized that these non-doctor doctors, if you will, emergency or -- surgery capability, if there is actually a solution -- a long-term solution for developing countries from the resources side -- if it is one that everybody here agrees that is actually a solution or it's not -- and if it is, are there actually -- is there going to be a focus in terms of funding training specifically for these kind of professionals.

COLEMAN: You've been very patient over here.

QUESTIONER: I have a question, though, I'm not responding to --

COLEMAN: No, no, that's okay. I think this is a very big question and I think we've talked around a lot of different parts of it already today. So we'll get a few more out here.

QUESTIONER: Actually I have two very short questions -- one is perhaps for the representatives from donor countries and recipient countries. I'm wondering if -- when you think the appropriate time is to start prioritizing and planning and figuring out how to maintain all of these people that we're putting on antiretroviral treatment. It seems -- at this point, it might be something that is going to come after 2015 but maybe there's work already being done that I don't know about. I think in India there's work in producing these drugs in country and I'd like to get a better understanding of that.

The second question might be for Maryellen and anyone else who could help to answer this. I'm curious why the USAID, why U.S. government, USAID funds post-abortion care but not, obviously safe abortion. And within that -- and that's not a -- I worked with -- (inaudible) -- for a long time and I was always curious why I think it was because there was evidence -- there was strong evidence to suggest it was a main killer -- but why was that successful and yet we can't use that same sort of argument for safe abortion?

COLEMAN: (Off mike.)

QUESTIONER: On the last question, it's very simple and it's very political -- the issue of post-abortion care is the abortion has happened; it's not an indication that the U.S. government is promoting or supporting abortion. And in fact one of the leading opponents of abortion in the U.S. Congress, Representative Chris Smith is a strong supporter of post-abortion care. He says it's the humane thing to do.

So it's -- you know, it is a statement of, you know, this is a problem that's happened and we can take care of it but we won't contribute to it. I'm not endorsing that to you, I'm simply repeating it. (Laughter.)

COLEMAN: Paul is going to give a quick answer on the -- on your first question.

QUESTIONER: It's a quick answer -- there's no simple answer. But very clearly we're in for the long term on antiretrovirals. And, I mean, we have committed to really keep the drugs flowing to countries. So, I mean, it's not an option to stop.

What needs to happen is to increase the importance of HIV prevention activities because now we're really lagging behind. And, of course, I mean, another global health issue, the issue of access to drugs and diagnostics and vaccines and some -- we desperately need vaccine -- yes. And also we desperately need more drugs and we need them at an affordable, acceptable cost, meaning competition and all the dealings that basically have to do with business and demand so on.

So it's -- but it's very clear. I mean, it's not going to finish in 2015.

Maybe what I -- the one thing which struck me when listening to this very rich discussion -- I come from a country where -- and you should not seem what is set in stone in terms of policy's going to stay there forever. So, I mean, the point that was made about working on -- really to get a bipartisan broad engagement is important because what I've been saying today might not have been something I could've said five years ago. And it might not be something I could say 10 years ago -- so -- or 10 years from now. So it's really important to work on bipartisan.

The other thing, just reflect on an increasing debate in Europe which maybe also is happening here in terms of the legitimacy of AIDS. I mean, first of all, 0.7 percent GNI should really be a target also for the U.S. government. If we get 0.7 percent investments, that would basically solve many of our problems.

But the public is increasingly demanding a higher focus on results and on transparency of what the funding is being spent on. So my advice is really now in the next few coming months -- I know that FCI and others are working on this -- success stories in maternal health are needed. We really need success stories told in a very succinct manner, powerfully to policymakers -- decision makers. There are lots of them, we are not good enough in terms of putting them forward.

The second point is around I think it's great to talk about human resources. Let's also be very clear about the information management systems. We don't have enough data. We don't have enough information and not least in the field of women's health. We're really lagging behind. It's not acceptable when a country says maternal mortality is somewhere between 400 and 800 per 100,000. It's -- (laughter) -- I mean, and that's where child survival has made a good point. We're able in child survival to be very much more precise. We need to do the same thing in women's health.

And one thing which is possible when working on data, if to get the right approach of really putting accountability where it belongs, to performance management which is really what it is all about -- if we get the data, we're better at planning, managing evaluating and so on, but we're also better at applying rights-based approaches because we have data we can act upon.

COLEMAN: Thank you.

We had planned on having the Ethiopian health minister, Minister Tedros, here with us today who would have been able to communicate one of those success stories -- Ethiopia has dropped its maternal health -- maternal mortality rate almost by a third now through a whole system of community health workers.

This is our -- unfortun