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NGOs and Global Health Governance

Speaker: Helene D. Gayle, President and CEO, CARE USA
Presider: Yanzhong Huang, Senior Fellow for Global Health, Concil on Foreign Relations
April 13, 2011, New York
Council on Foreign Relations


YANZHONG HUANG: OK, let's get started. The conference has a tradition in always starting in time -- on time, and end on time.

So, welcome to the Council on Foreign Relations. I'm Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations.

This is the fifth meeting in the Global Health Governance Roundtable Series, and our third and final in New York -- I mean, for this budget year. (Chuckles.) And we are thrilled to see many of you again, and very excited to see some new faces.

And we will begin with brief remarks from Dr. Gayle. And we won't take time away from our speaker with her incredible biography. Safe to say that Dr. Gayle is president and chief executive officer of CARE USA, a leading international humanitarian organization. And Dr. Gayle is an expert on health, global development and humanitarian issues, and she has spent 20 years with the Centers for Disease Control, working primarily on HIV/AIDS.

And Dr. Gayle is named one -- I think she's a person who doesn't need introduction -- (laughs) -- but I still want to point out that she's named one of Foreign Policy's top 100 global thinkers and Newsweek's top 10 women in leadership. And she has been featured by national and international media outlets, and has published numerous scientific articles.

So without further ado, Dr. Gayle, you have 10 minutes.

HELENE GAYLE: Great, thanks. And thanks for keeping it brief. You know, as you -- as many people know, you know, when you are speaking, your team sends forward your bio. You don't have any clue what's going -- what -- how they're going to announce you. And I have one bio that I think I've changed, but it goes through -- you know, he mentioned being featured in media outlets -- and it goes through, you know, old magazine, Glamour, Newsweek. (Laughs.) You know, it's like -- so to me, the height of my career was being featured in Glamour -- (laughs) -- but forget all the rest of those. But then I think we took that out.

Anyway, so I'm going to speak very briefly about kind of the perspective of an NGO. And I know a couple of people who are here have spoken at this roundtable too from a different perspective. And as mentioned, you know, I have worked open government, with the Centers for Disease Control, then in private philanthropy and now with an international NGO. And, you know, in all of those, health has been a feature in the work that I do.

Now, at CARE, I'm able to step back and look at health in a different way in the context of a development agency and an agency that's focused on long-term sustainable development -- and health is a piece of that -- versus my other roles where health was the central feature. I worked for, you know, CDC and then Bill and Melinda Gates, always in the -- with a focus primarily on health and health institutions.

And so for me, it's an interesting change to be looking at health from the broader context of a -- of the development landscape and in this context of governance, which maybe might be one of the things we even want to talk about, what is governance, because I think we all think about governance in very different ways, but you know, the different actors that are part of health governance from the perspective of the overall development landscape. And maybe we'll talk a little bit more about that.

For those who don't know much about CARE -- and I imagine most people do, and I see people who are here from sister organizations -- but we are one of the large international NGOs, working in about 80 or so countries, with the overall missions of having an impact on the poorest communities around the world and looking at how we can help in the fight to end global poverty, but really shifting, as many of us have, from being primarily service providers to really looking at how do we provide communities the capacity to really make a change and make long-lasting change. I think we've shifted a lot from looking at how do you develop -- how do you provide good services to how do you have a longer-term sustainable impact on catalyzing change.

And I just say that because I think that has a lot to do with who and how we work at the community level. We also work very much in a way that looks at how do we -- how do we build a dialogue between the communities we serve and the other actors that have an impact on those communities and how do we do more to make sure we build resiliencies within -- resiliency within communities and also build within communities the sense of their rights, and work with governments and other agencies to build a sense of their accountability, and how do you put those two actors together.

And I think that's -- again, has a big influence on the way we view our role in global health and global health governance. It is this dance between the rights of individuals and communities and the responsibilities and roles of governments and other institutions to be accountable to citizens and -- you know, and looking at how do you influence on both sides, so that at the end of the day, when you think about health, we've improved the ability to have greater access to health, greater sense of individuals' rights for health and greater skills to be able to provide services that are relevant to the needs of communities.

So yeah, I think when we step back and think about the global health landscape and global health governance, all of us realize that as a result of new actors and new resources, this issue of global health governance has gotten just that much more complicated. And on one hand, we all look at the global health landscape and recognize that there are new resources; there are new actors, you know, resources like large foundations more and more being engaged in this; new private-sector engagement in health. I look at Derek and the role that a company like Pepsi is increasingly playing as a major health actor on the scene.

And with this proliferation of actors, I think this whole panoply of issues related to governance, whether it's standards, whether it's measurements and strategies, accountability, all of this has become much more complicated.

And the -- and the fact that health is no longer seen only in a very narrow health box, if you will, where health agencies and public health agencies were at one point the only ones involved in it, again, looking at an organization, agency like mine, or Carolyn's (sp) or others that are very involved in it, and the fact that people are now seeing health more and more as part of the foreign policy landscape, and it's, you know, why there is a global health program here in Council -- Foreign Relations or CSIS or other organizations that used to think of themselves as -- used to think of foreign policy as a very different enterprise and now we see more and more the proliferation of global health task force or global health divisions within organizations that used to be thought of as only foreign policy.

And many of us have followed the saga of HIV/AIDS over many, many decades, where the greatest increase in HIV resources was when HIV was characterized as a national security threat. So I think as we look at the ways in which health has become part of a much broader scene, it also adds to the whole complexity of global health and global health governance.

So -- and I think some of those issues would be interesting, as we open up to the broader discussion, to really think about what does that mean when we think about how do we have a system both at a global level as well as at the country level and local level that can assure high-quality health outcomes that -- some of which derive from high- quality health services but that go well beyond that, that have to look at the policies, the range of different actors, and then the role that the community plays itself.

I'll just kind of -- my final comments are around -- to be specific, around some of the ways in which we as an international NGO look at this issue of global health and global health governance. As I said, obviously we're a(n) organization that is much broader than health. We focus on everything from agriculture, water, microfinance, education, all with the sense that we have to look not just at the immediate human needs but also look at what are the underlying causes, what are the issues that fuel and keep people trapped in poverty, not just how do you provide good services.

And in that context, we see our role very much as looking at working with these partnerships between communities and other actors, looking at a much more decentralized approach to governance, where we try to make sure that this marriage between rights and responsibility, how do you actually fuel the community, how do you have communities understand their rights and make a health system accountable accordingly, and looking at how do we really shift the balance of accountability such that there is greater transparency, grater involvement and greater engagement across all the range of actors who are involved in that.

We look at how do we take our programs, for instance -- we have multiple examples where programs at the country level that have been successful have been able to be transferred to governments and other actors, taking pilot activities and working -- developing advocacy that actually transfers what works to the broader policy arena with the hope of making sure that the things that make a difference and that are known to have a real impact are what then become standard in a given context.

I think I will, you know, kind of stop there and just, again -- you know, I think for some of the discussion and some of the give and take in questions, you know, ask a few questions, and I think it would be interesting for us to talk -- to grapple with what does governance -- Andrew is a political scientist. I was just asking him what is his actual definition of governance and what does it mean and how do we see that, how do we see that in -- both at the very, very global level, where many of us have played or play, but then how does that translate to what happens at the community level and how do we do a better job of making that dance.

And I think as an international NGO, we have the potential to kind of be at that nexus between what's at the global level, what's at the country level and how do we build that bridge between communities, the broader policy arena, both working to influence players at the country level but also making sure that what happens at the global level takes into consideration all of those different levels as we think about governance, accountability and better standards across what we do in global health.

Those are just some thoughts. I'll stop there and see what -- what that inspires.

HUANG: Thank you, Dr. Gayle.

And before we get started, discuss the questions which were raised, I actually have a more general and a specific question to ask -- general because it's about essentially the role of NGOs in global health governance, and specifically because this about one particular type of NGO. We know that actually in your bio it said -- it says that you have worked at the Bill and Melinda Gates Foundation directing programs on HIV/AIDS and other global health issues. And we know that since its creation in 1999, the Gates Foundation has disbursed more than 10 billion U.S. dollars in global health grants, and today it controls 58 percent of all private giving for global health. So the scale of the foundation's resources has made it, some people say, the game changer in global health governance.

I was just wondering, is that good, bad or otherwise for global health governance?

GAYLE: Well, yeah, and it's a question that comes up a lot. When you have -- and, you know, in my comments I kind of alluded to, you know, the fact that there's this whole new range of actors, and I think it makes governance much more difficult.

And it particularly makes governance more difficult in some ways because some of the new actors are not beholden to anyone, if you -- if you will. I mean, they're not beholden to public like -- you know, when I was at CDC as a public servant, I was beholden to the American people, if you will. You know, I think when we -- in roles like the role that I'm in currently, I think we believe that we're beholden to the communities that we serve and that we're -- we are accountable to our donors and we're account -- you know, broadly speaking, we have those measures of accountability.

I think when you are a large private institution, your accountability is to -- tends to be to your overall sense of hoping to make a difference, but that's very -- that's very different than having a tangible group of stakeholders that you are absolutely accountable to. So I think it makes it a lot more complicated, and I -- and it is why, I think, we struggle with this issue of global health governance today in ways that we didn't when there were public sector institutions with the bilaterals, the multilaterals, when WHO was seen very clearly as THE institution responsible, in a way, for global health governance. You know, now even within the U.N. system, there are more organizations that are involved in global health -- rightfully so. And I think it's good.

But, you know, again, I think as global health has broken out of a strictly health box and there are more institutions that are involved, it becomes a much more complicated endeavor than it was when it was primarily health institutions, primarily public sector institutions. And when you do have a -- an organization as large as the Gates Foundation that is putting out lots of resources -- which is a good thing -- but has no specific accountability other than to itself, if you will, you know, I think it raises real challenges.

HUANG: So basically you are suggesting that governing the Gates Foundation is as challenging as -- in its own way as governing the United States --

GAYLE: (Laughs.) Well, there are many forums where, you know, you have U.N. bodies and then the Gates Foundation as part of, you know, intergovernmental bodies. So, you know, when you have those many resources, your access and your influence is obviously very great. And so I think it is up to us to kind of tackle -- to grapple with this really complicated set of actors that have changed what has been traditional governance. I think, you know, the days of having it all fit into a public sector box are over. And we really do have to think in a very different way just like -- you know, in the kind of the policy realm, there are no longer just states. There are also powerful nonstate actors that have huge impact on foreign policy. And I think, you know, broadly speaking, we're having to rethink our governance structure, because they don't fit today's world where there are just many more powerful actors. And global health is no exception.

HUANG: Thank you, Dr. Gayle.

Now I'm going to open up the floor for (asking ?) questions and discussion. And please identify yourself and your (organization ?) before responding.

And also, I forgot to mention that this meeting is on the record, so you can feel free to use --

GAYLE: On the record.

HUANG: -- and -- it is on the record.

GAYLE: Oh, oh, oh, okay.

HUANG: It is on the record.

GAYLE: Oh, okay. (Laughter.)

HUANG: (Off mic) -- well, we can still change the rules if you --

GAYLE: No, no, no, I'm just -- I'm just so used to the Council on Foreign Relations; you say, you know, this is not for attribution and, you know, whatever. So -- yeah.

HUANG: So --

GAYLE: I really didn't say anything I said. (Laughter.)

HUANG: Okay. Well, you --

GAYLE: (Off mic.)

HUANG: If you don't mind -- (chuckles) -- so -- I guess you can feel free to use and quote today's discussions. Please also turn off the cellphones. And please flip your tent card to indicate that you have a question. And we also allow the (one-finger ?) rule. So, you know, if you have a follow-up, you know, quick follow-up remarks that -- we can allow that as well.

Any questions? Jeff.

QUESTIONER: Hi, I'm Jeff Sturchio with the Global Health Council.

I wanted to pick up on the comment you just made about how the structures we have for global health governance haven't kept up with changes in the world. I was at an interesting meeting on Monday night. There was a group of visiting African health officials who came to Washington. They're actually in New York now. And I was at a dinner where we were discussing country ownership. And one of -- so one of the points I just wanted to make in addition to what you were just observing is that there's a real tension between organizing things around the needs and interests of communities and what's usually meant by country ownership.

GAYLE: Right.

QUESTIONER: And this came -- this came out very starkly in this discussion on Monday. The reason I mention is that one of the officials from a country in East Africa got up and went on a tear about -- you know, in a very polite way -- but was really quite exercised about the notion that country ownership has to mean that the government is in control, because you can't have NGOs coming from outside the country to work with communities without coordinating with the government.

So there was one very clear illustration of what -- you know, one school of thought about country ownership. It means the government's in control, the government -- whether it's the health ministry or other ministries -- has to -- has to manage.

And then another example that, you know, several of us are aware of too is that the WHO now is grappling with the notion of how civil society can be part of WHO's deliberations through the discussions around a forum of some kind that Margaret Chan has started after the executive board meeting in January.

So I just think that this tension between what communities need and what other actors can add to the solutions to those communities -- namely organizations like CARE and many others, some of which are represented here -- there's a real tension between that and what goes for global health governance in most of the international institutions that are addressing these issues.

So my question is just a very simple one. How would you change the institutional governance of global health so that the role of communities, the role of NGOs, the role of the private sector, all of -- and foundations like the Gates Foundation and others -- all of which are making contributions equally significant to the contributions that either intergovernmental organizations or governments themselves are making -- how do we change institutional structures so that you have a complex but workable system that actually reflects all of those interests in -- and reflects just how complicated today's world is?

GAYLE: Yeah, that's a simple question. (Laughter.) Yeah, well, you know, I think one -- let me -- let me start by the comment that you said the minister made. And I think it's an important one, because, you know, as everyone in this room knows, you know, we have -- as the U.S. government has really taken this language and approach of country-led programs as the way business is going to be done, but, you know, most of the institutions work government to government, and country ownership does tend to end up being what that government in that country says needs to happen.

And while I totally agree and believe that governments, legitimate governments who are acting on the -- you know, in -- with the best interest of their people in mind, ought to be the ones coordinating what happens. And we shouldn't have a proliferation of external organizations, you know, making policies, doing programs, et cetera, without the coordination. And if you have a strong government and a capable government, that's the case. And part of what we and, you know, organizations like ours do is try to strengthen governments so that they're more able to take that leadership role.

That said, what often happens is that legitimate or otherwise governments aren't necessarily in touch with communities and with people, with civil society.

And so it's a -- you know, part of, again, what we see our contribution to improving governance is improving civil society's ability to interface with government and to make sure that their rights are exercised and, you know, ask for greater accountability. So that's one -- you know, I think that's part of the answer, is the more we can have invigorated civil society, the less you need to have additional structures and the more governments will be actually responsive to the needs of their citizens. So if we do a good job of that, we don't necessarily have to keep creating new structures. That said, I think we're not there yet. And looking at ways -- you know, whether it's forums like the WHO is proposing, you know, or other structures, there needs to be these other voices at the table as we work on strengthening government's ability to actually be responsible.

I also don't think it necessarily means creating a lot of new structures. But there are maybe -- there are potentials for creating new mechanisms; so, you know, accountability measures. How can we have transparency in what actually happens so that there is a greater ability to hold governments accountable? And I think if we can -- you know, because again, I do believe that governments -- just like I think ours ought to have a responsibility for making sure that health is assured for all of its citizens who can't afford otherwise. But I think there are ways of making governments accountable by, you know, more transparent processes, you know, greater engagement; because I think if we try to fix it all by creating new structures, we will -- you know, we will be hampered under the weight of, you know, now let's have an NGO forum, and then let's have a private sector forum, and then let's have a philanthropy forum for health, and have all those structures. And then they meet, you know, and you can see the cross matrixes and how complex it gets.

So, you know, I would -- I would focus more on -- less on what's the perfect structure, and more at how do you get the processes fixed and the voices heard and the accountability and transparency there so that the structures that are already in place work better and are, you know, more accountable.

HUANG: OK. Derek (sp).

QUESTIONER: Thanks, Helene, and wonderful to hear you speak.

I think the -- I think the timing we're in now reminds me in some ways of that period in the late '90s, which were the declining years of the Nakajima era. And the debate at the time, as we can all remember, was about the fact that we were starting to see the promise of other players coming to the table. WHO was failing in its mission, particularly on HIV/AIDS. There was a concern that it wasn't able to assert the kind of leadership that was needed across the U.N.

And very interesting in that period which -- was that the organization to change was happening in two ways. WHO actually had an executive board series of discussions on constitutional reform, not unlike the discussion that happened at the board this year and the meetings that followed. But at the same time, there was an outside- of-WHO group that had assembled to push for change, led by the Rockefeller Foundation, the Swedish government and the Canadian government.

And I raise that because I don't see that second starting to happen now. And I just wonder how an organization that's going through such cutbacks -- we're seeing huge cutbacks now -- has got the capability to reform itself, and whether it's going to take the equivalent then of bringing together the best of the foundation/corporate/NGO world to actually get themselves far better organized -- independently initially of worrying about the U.N. system -- to think about what is best for world health over the long term, and then recognizing their need to come together.

The first time round, it failed to -- we got a change, of course; we got Brundtland. But we didn't get the reforms that were even agreed by the member states. And part of the reason was that the reforms got put on the table in the same year that a new director general was being voted. And that I think is a danger we're facing this time around, as well. The reform process is now being aimed at getting to the table in the same year that a director general is going to be elected.

That is a -- that is a recipe for disaster, because it means the two are going to be seen as playing off each other.

And I raise both those questions -- it's how better can those groups outside get better organized and if there's a need for that to happen, and how -- I'd be keen to hear other people, particularly we've got people from within WHO in the past and without, think that in fact this time round, the last decade has -- decade and a half has shown that the power and the operational capability and many of the science capabilities have now moved out of WHO, and that is a fact. How do we adapt to that fact, rather than trying to hanker back to a reality that existed 15 years ago?

GAYLE: Yeah, and I'm sure others have thoughts on that it would be interesting to hear.

I guess, you know, I would just -- one, I think, you know, the WHO is still necessary, and you know, I think there is a need for a redefinition of what WHO's role is in a world where there are so many other actors and where the view and vision for global health is a very different one than it was when the WHO was first created.

So you know, I think, one, you know, coming together -- and it's probably member states along with, you know, some other important outside actors, thinking about so what is the role of the WHO today and can we agree on that? And I think it's -- you know, I think we haven't done that in a while, and I don't think that everybody agrees on what the rightful role of the WHO -- I think if you talked to WHO people versus people outside of WHO, you'd get a very different -- some very different views on that.

I think the structure of the WHO needs to be revisited. Are there regions that -- you know, the regional structures, as currently comprised, the right configuration? Do you need regional structures if in fact the WHO's role is much more the global normative standard- setting role, you know, which is one idea of what WHO should be.

So I think there's a lot of rethinking that needs to be done, but there has to be a willingness on -- you know, on the part of whoever leads WHO next to actually have that -- you know, that, you know, redefinition or thinking strategically about what its best role is, and then, given that, how should some of these other organizations align themselves accordingly? So, you know, when WHO was created, there wasn't a Global Fund, there wasn't a GaBI, there wasn't UNAIDS. You know, are they still the right, you know -- and I know UNAIDS is rethinking its role a little bit, you know. And so first thinking about what's the right role for the -- for WHO and then looking at, given that, how do these other kind of global organizations align themselves accordingly -- foundations, et cetera -- I think we could do it, but there would have to be a real willingness, and maybe there needs to be a group of people who are feeling the pain of the lack of coordination -- you know, need to get together and be more vocal about it.

You know, maybe they're -- maybe they're -- that's what could come out of this group, you know -- (chuckles) -- you know, a group that works on -- you know, what would that look like and what needs to happen?

But I think we -- I think that we're in desperate need of that rethink.

HUANG: Yeah. Just, Dr. Gayle, for your information, our last roundtable was about the relevancy and the effectiveness --


HUANG: -- that WHO show in global health governance. Jack Chow also agreed that the structure of the WHO needs to be changed. In fact I think right after he published an article in Foreign Policy basically very critical and very pessimistic about the future of WHO.

GAYLE: But you know, the thing -- I'd -- we all talk a lot about it, but I'm not sure what is it going to take to actually push that kind of change and I -- so -- anyway, I'd like to see -- I'd like to see some action on it, but --

HUANG: Carol (sp).

QUESTIONER: Thank you, and thanks, Helene. It's great to see you in New York and great to year your comments.

A lot of what you talked about was about the different actors that are now on the scene in terms of driving global health. And one thing that occurs to me is the value of coalitions, of bringing those actors together.

So I'd love to hear a little bit from you on what you think some successful coalitions have been, what -- the best way to organize those coalitions. Is it around specific health issues? Is it around overarching issues?

And then finally, it seems like there should be some lessons learned from the HIV/AIDS work, and you've been very involved in that. So are there some things we can take from there around building coalitions that actually drives action?

GAYLE: Yeah. You know, you might want to speak to saving newborns' lives, for instance. I mean, you know, I think that there -- I think that the coalitions or the maternal -- PMNCH -- (chuckles) -- yeah, I think the coalitions that have worked the best have been the coalitions that have focused on specific areas. So, you know, maternal mortality, HIV/AIDS and newborn health, yeah, I think in those have worked well because you have people who are aligned around a common goal.

I think the coalitions that haven't worked as well have been the ones that have been general -- we're similar sort of organizations; let's all work together. Well, there -- I think that hasn't worked as well; there -- because there's not that sense that we've got a goal, we've got an objective, we've got something that we want to work towards.

But I think those models are really actually quite useful and have helped to better coordinate the efforts both at a global level and at the field level and have helped to really be an important advocacy voice, which, you know, continues to be as important, I think, as what people are doing at the country level.

So, you know -- and I think a lot of those models are similar to the kinds of things that we did in HIV/AIDS, where by developing coalitions around pieces of it, whether it's, you know, prevention or treatment, preventing mother-to-child transmission -- but I think those kind of clustering of people who have very common goals and objectives have been part of the way that those have -- you know, that I think those have been very useful.

And I don't know if you want to say anything from, you know, saving newborn lives --

QUESTIONER: Well, I mean, I guess I -- that, I think, has been borne out. I think my question is whether those kinds of coalitions, and particularly the ones around specific issues, can help in terms of this governance issue, if there's -- if there's things we can learn through driving those coalitions. In other words, are we -- is part of the governance issue that there -- it's too diffuse in terms of the issue of global health governance and in fact what we really need to do is work on the specific issues around global health, or is that not really going to get us there?

GAYLE: I guess I think it gets us part of the way there, because I think it cuts down on the stovepipes that people -- everybody doing their own thing, working in silos. And I think it really does, at -- particularly at a country level, present a less confusing picture, so people are actually working -- looking at comparative advantages, working in a way that's complementary. And so I think in a certain way it serves as its own governance mechanism and really helps in a lot of ways, you know.

So I think the biggest lesson learned is -- I think actors work better together when they have a common goal. I mean, that's kind of straightforward and simple, but I think sometimes -- you're right -- when we take this kind of very diffuse approach, it's real hard to get your arms around it and to be tangible. But I think when there aren't very specific goals, it is easier to have people coalesce. But I think we need a little bit of both, because there still is the broader governance challenge of all of the different actors at, you know, kind of global levels, each coming up with their own way of viewing the world, their own policies. And I think there is a need to kind of harmonize that that can't be just disease or issue by issue.

HUANG: Emmanuel.

QUESTIONER: Emmanuel d'Harcourt from the IRC. I'm very tempted to go back to the WHO topic, but since the meeting is on the record -- (laughter) -- I will hold off from doing so.

But I wanted to pick up on some -- on Jeff's question regarding the -- sort of some of the fundamental issues of governance that aren't particular to Gates. There are unique issues with Gates governance, but really there's a common thread, whether it be foundations or governments or other donors, as well as implementers, such as our organizations or your companies that are both donors and implementers, that there's a mismatch between the clients, in a way, and the -- who the organization is accountable to, if they are accountable.

There was a piece -- I don't know if people saw it -- in The Wall Street Journal on Monday, which was kind of a somewhat typical Wall Street Journal hit piece on humanitarian aid about somebody who was working in Somaliland, but it does bring up some troubling points, that basically we're not accountable in a very binding way to the beneficiaries, so (personally, we would be ?) -- I think would all think of ourselves.

So one issue that I totally agree with that you mentioned is just information transparency, which promotes accountability, but the other is in terms of giving people choices, which I think that piece in The Wall Street Journal referred to. And one way that's been put is as cash transfers. Another way is that -- so that people could actually have an option as to how to spend money and, you know, sometimes might not choose health, but I was curious to know both your opinion on these issues and if CARE had any experience doing that as a way, as a mechanism, as you say, one of those improved mechanism within existing institutions to improve accountability.

GAYLE: You're saying cash transfers specifically?

HUANG: Cash transfers or other mechanisms where basically the value of the work is -- you know, people have a way of voting on it in the way that people have a way of voting on which soda they use.

GAYLE: Some, not a lot. I mean, I think, you know, partly -- and I saw you nod. I don't know if you want to say anything about it, but I mean, I think the idea of using cash transfers as a way to drive this issue of people having the ability to put their money behind their rights, which I think is what you're talking about in terms of health, right, and being able to say, OK, well, now I actually can vote with my -- with my dollars.

I mean, we have found that in some situations that's worked very well, and I think it's a different way of doing what we've all been talking about, which is making sure that communities can, you know, have access to their rights to health, and this is one more way of -- I mean, sometimes that is the way you need to -- you need to drive those things through. So I think it has been successful in some cases.

Yeah, and you know, that's -- that said, one of the challenges for an NGO like mine, like yours is that we are so donor-driven, and I think, you know, as you said, you know, we like to think of ourselves as being accountable to the people we serve and the communities we serve, but those communities have much less leverage over us than our donors. And so I think part of it is also looking at, how do we change donor mentality around accountability and give organizations who are working at the community level a greater ability to come up with accountability measures.

You know, the cash transfers, you just said, has worked well in some situations. You know, there's a range of ways in which there can be greater accountability, greater flexibility, greater transparency, but it is very difficult when most of your time is spent being accountable to donors. And I think donors need to think a little bit more about, what are ways in which organizations that use our resources can be accountable but with greater flexibility.

Is there a way of having, you know, more milestone and performance-driven versus the kind of very detailed, you know, accountability reports and measures that are typical of, you know, the donor-recipient relationship? And that's also for ourselves, who then oftentimes provide resources for indigenous in-country NGOs. How can we do that in a way that also allows their greater flexibility, more accountability with communities, et cetera? So there's this whole chain that happens, and I think we need to reverse a little bit and figure out, how do we do that dance a little bit differently.

HUANG: And maybe your NGO could also contribute to that discussion as well.

QUESTIONER: Thank you very much. I'm Ann Starrs from Family Care International, and I wanted to bring it back a little bit more to the topic, the specific topic we've been talking about, about the role of NGOs in global governance. I've been on the board of the Partnership for Maternal, Newborn and Child Health for six years and have been also engaged with the boards of a couple of other global health partnerships, the Global Fund and less so the GAVI Alliance.

And I did at one point a sort of scan of what is the role, what is the proportion of NGO or civil society representation on the boards of various global health partnerships. And what was interesting was that the ones that had the most money to give away had the least NGO representation. The Partnership for Maternal, Newborn and Child Health, which is primarily an advocacy organization, has -- half of the board is civil society representation, which is, I think, not surprising.

But I wanted to come back to one of -- one of the issues that has been challenging for me and for, I think, many NGOs that are direct participants in governance structures for global health, such as these global health partnerships, is that there is, I think, a real tension between sitting -- having a seat at the table and being part of the policymaking and the decision-making that happens at that global level, and there's a -- there's a tension between that role and the role that you've talked about -- or the roles you've talked about -- about representing communities and also representing or being advocates for specific issues.

Because when you're part of an entity like a board, like a governing board or a governing council, there is an expectation that part of your role as an individual is to support and buy into and contribute to the decisions. But then there's also -- particularly for an advocate or if you're representing a community perspective, the role is to be critical and to -- and to hold these institutions themselves accountable. And I think there is a real tension between those roles that is sometimes difficult for NGOs themselves to face. And then they also -- it also comes in, of course, with this issue of the -- being donor dependent. That also comes in and plays into NGO roles.

So I just wondered if you had any insights or any recommendations for how the global health community and NGOs themselves might deal with this tension, or if in fact you've observed it yourself.

GAYLE: Yes, it's a good point. And I -- you know, I think about, as you were saying, when you did that poll and those who had the most money and the least representation -- you know, I think about sitting on the Global Fund board for several years. At that time, I was representing the Gates Foundation, so it was a different role, but I remember the NGO representatives who -- you know, as you said, their role was often to be the more critical but they were also oftentimes dismissed. And I think it is a very, very difficult role to be in. You're trying to bring the voice of civil society, you're trying to give an alternative view, but you are in this role where you're often the least powerful. And there are clearly, you know, as we know, power dynamics within boards, and they tend to go along who has the resources.

So, you know, thinking back to what you were saying, Caroline (sp), you know, the HIV/AIDS epidemic, part of the reason why there were such powerful civil society voices -- you know, no matter what the organ of governance was -- was that many of the civil society actors were very empowered. And so, you know, in the United States it tended -- in the early days, it was gay men who were very personally empowered and able to be very, you know, strong spokespersons. As the epidemic shifted and as it became more developing-country focused, that changed; but because the civil society voice had always been so strong, some of that was transferred.

And so, you know, maybe some of the answer is: How do you start with voices that are relatively more empowered, and transfer some of that power to the less empowered, once people have gotten used to the fact that, yes, you know, there's a civil society that is willing to clobber us over the head? So, you know, that may be part of it, is: How do you develop those coalitions between parts of civil society that are relatively empowered, and have that coalition be a more powerful voice?

HUANG: OK. Ariel (sp), but we have to discuss that. There seems to be two conflicting trends. There's -- on the one hand, seems that those who have the most money have the least of representation. But on the other hand, as Dr. Gayle has indicated, that most of the NGOs tend to be donor-driven. So how -- what's your take, you know, as you're managing it as a donor, on this issue? (Laughs.)

QUESTIONER: Thank you. Thanks, Helene.

And you were asking at the beginning: What do you mean exactly by governance? And then you could also say the same thing about global health. Is it we're talking about the actors, the agencies, working in international space? Is it the donors who are throwing the resources, and so on? Or is it the people you are trying to serve?

And so how do you construe the -- a conception of global health and the governance for it?

In the end, it comes to money, but actually it's always more than money, and you've spoken to that. Global health in the international space of dollars -- accounting dollars, has drawn tremendously, $5 (billion) to $25 billion in the last decade or so, and yet this is less than 0.5 percent of the total spending in health in the world. And of course this speaks to the inequities in the world today but also speaks to a certain blind spot to what we mean by global health.

And as we -- as we sit here, health spending is growing dramatically around the world. And despite the recent recession, economic growth is taking in unprecedented ways around the world -- and that means that many of the countries we used to see as needing aid and so on, so forth -- many of them are growing strong, strong in different ways. But importantly, a lot of that growth in economics and growth in health spending has unfortunately been out of pocket. People are spending their money in countries.

And so as this is the case -- that is, even in sub-Saharan Africa, the overseas development aid is 5 percent of the total expenditure -- is the people's own money, is the government and the people's own money.

So what do we mean in -- when we discuss your -- the way in which you work, Helene, in countries when it's -- really the money is -- really, the most important amount of money is right there in the country. Are we tapping that and are being accountable to those possibilities and aligning those resources to serve the people best? And from that, what form of global health governance can we envision?

GAYLE: You know, I think -- yeah, you're right. This whole area of tapping into in-country resources and what that means -- and it kind of gets back to the comment that Emmanuel made about things like cash transfer, because if you give -- you know, whether it's -- whether it's cash transfer or whether it is an individual using their resources, what would they choose? What would they actually choose if they had the option, and how can that drive our systems better?

Because if people are voting with their money -- and you know, I think that can be a very, very powerful bloc, if you will, a very, very powerful, you know, force for change. And part of what, you know, I think we don't do well enough is look at what -- you know, what are people saying with their resources? Are we capturing that, as you said, and are we then using that as a lever for change, for looking at what does it mean for, you know, governance? And ultimately government -- governance is a -- is a process that hopefully leads to change that enables better outcomes.

And I think if we did a better job of really looking at what are -- what are people truly telling us with the way that they use their resources around health, and are there needs to shift that or not shift that? So you know, if people are saying, you know, I would rather pay for a traditional practitioner in my community, because going to that health system is just as -- you know, is just as bad as staying at home and doing nothing, you know, then I think that puts a different pressure on that health system, and feeding back that information would be -- you know, I think would be very powerful. So to me I think -- you know, again, I'm not sure what it means in terms of setting up a governance system, but I think it is another way that we could better capture information that could be a lever for change for policymakers, whether it's in the country or, you know, at a global level.

HUANG: Thank you.


QUESTIONER: Howard -- (off mic). My question really is one -- (audio break).

GAYLE: Well, you know, the next disaster -- you know, the bottom line, I guess, in many ways is that it would be great if the next disaster occurs in a country that has a functioning government.

You know, I think -- you know -- (chuckles) -- well, it just did -- (laughter) -- I mean, it just did. And, you know -- so, you know, be careful what you ask for.

But anyway, it just did. And I think you see the difference. Obviously, there's light years between Japan and Haiti, but I think that's -- you know, I think fundamentally, had Haiti had a functioning government, a lot of what we've seen would not have happened. You know, there was a huge -- you know, as everybody knows, a huge outpouring of resources, a huge outpouring of support. Every -- you know, when I was on the plane going there to Haiti, you saw every church mission under the sun sending volunteers there. You know, I couldn't keep up with my email from every person who had any interest in Haiti, wanting to know, can they send their child down there to do volunteer work, et cetera. And there was nobody to coordinate it really, you know.

And so I think, you know, our coordination mechanisms, particularly in -- you know, in times of emergencies and real stress points has to be strengthened, but we -- you know, it is partly strengthening, you know, whether it's the U.N. system for issues like emergencies, which, you know, I think work relatively well -- but unfortunately the U.N. was also, you know, really struck in the process -- but doing what we can to strengthen government's capacity to coordinate -- because, you know, if there is not ownership, this is when government ownership makes a huge difference. If there's not somebody there to say how do we want to plan our country when it's been decimated, you know, what we get out of this effort 10 years from now, you know, is very, you know, doubtful whether it's going to be in the -- whether it's going to be a chaotic outcome or not.

So I think that's the biggest lesson is that we've got to keep -- part of what our job has to be is to continue to make sure that we're strengthening the capacity within countries to handle, whether it's a complex emergency or other crises. And if there isn't a functioning government, then how do we, as players within those countries, do a better job of coordinating among ourselves? You know, I think that the coordination between the NGO community was actually much better than it was during the Asian tsunami. And I think we learned a lot from the Asian tsunami on how to better coordinate, not be as competitive with each other, and really look at what are the comparative advantages of the different organizations and really use that.

And so, you know, I think unfortunately sometimes it takes these incredible situations to force us to think about how to do that better. But I think that's -- you know, it's either strengthening the government's ability or making sure that those that are working on behalf of the people are doing a better job of developing those coordination mechanisms.

And I don't know -- Caroline or others who were involved -- Sam, you might want to make some comments about that, yeah.

HUANG: Do you want to -- do you want to make a comment?


: Just on the Haiti point, I think the reality is that 15 NGOs were 93 percent of the resources. So you actually ended up with quite a significant concentration of resources in a small group. I think the challenge is, you know, most of the hospitals, most of the health infrastructure was faith based and run locally.

And it sort of goes to my question. It is you -- you know, what is your vision of governance? Is it sort of a state sort of governance or a multi-stakeholder governance? And in a case like Haiti, can you have a vision of a state that's going to be more like France, or do you realize that that is not going to be -- and UNDP was sort of pushing in that direction -- whereas the reality is more, it is going to be multiple stakeholders, you have to accept the stakeholders on the ground, and then government work with those stakeholders to effectively put in a more effective health system but work from that reality?

And I don't know if that's just such a stretch for states to take in terms of country ownership, that -- you know, accepting that the -- you know, the eight major hospitals in Haiti are faith based and are still not necessarily run by the ministry of health.

GAYLE: Sorry, the question was should it be a multi- stakeholder? Yeah.

MR. : Well, I think that the question is what -- you know, can we -- do we need to get to a governance model that's going to vary country by country, where obviously there's a strong nation state, the state's going to run is, but we're going to have governance models, depending on the capacity of the country --

GAYLE: Yeah.

MR. : -- to engage and recognize that sometimes that governance model may need to be more complicated because you're going to have multiple stakeholders, even if that's more difficult for the nation state to accept; whether that is something that makes sense to you?

GAYLE: Yeah, no, I think so. And it's kind of back to Howard's question.

You know, I do think that, you know, you look at a place like Haiti, there wasn't a functioning government before. There definitely wasn't afterwards. So you -- that clearly isn't the governance mechanism. It has to be, who are the actors in place and what are -- you know, whether it's -- whether it's a U.N. role, if the government isn't functioning; whether it's the NGO quorum; or whether it's multiple, because, you know, there -- you know, as you know, in Haiti, there were really in some ways multiple different coordinating mechanisms, then had an overarching coordinating mechanism that helped to pull all the different actors in place. And I think the reality is, it has to be somewhat tailored to the -- you know, to the individual situation.

But I also think there needs to be then some link between that and then global structures. I'm thinking about how do you have that. Because, you know, if every country has its different model, there will be no sharing of experiences. There will also be, for some things that are truly global scale -- if you look at pandemics for instance, that can't be, you know, country by country. There needs to be something that is overarching that really does pull the more GLOBAL global health aspects together in governance as well.

HUANG: (And so you agree ) that if H1N1 outbreak -- (inaudible) --

GAYLE: Yeah, right.

HUANG: -- something that you've got to have actually a coordination of governance mechanism beyond international level.

GAYLE: But if we have the -- you know, if -- but if that will be enhanced by having thought about what happens at the country- to-country level, and if we have something -- you know, if countries focus on that and that exists, then that sure is a great foundation to build on when H1N1 -- (inaudible).

HUANG: Yeah. And the health capacity again to that issue.

GAYLE: Right.

HUANG: Danielle (sp)?

QUESTIONER: Yeah, I think just building a little bit on the local governance piece, and also having quite a bit -- worked fairly closely with the ministry of health in Haiti after the earthquake as well, (it seems that happened ?). I mean, it strikes me that the -- when I think of governance, I think of decision-making rights and that -- from a global level, and keeping the decisions that are driven from a global level and require implementation at a global level fairly constrained. But obviously there are some key ones.

But when you get to the local level and the local government that -- how do you really -- I mean, recognizing even in a country like Haiti that there's very limited capacity, how do you start at least empowering them with information and get the act -- I've not seen it work well in Haiti; I mean, there was coordination starting to happen with NGOs -- but really make true that the national government has the information abut how the system's performing, and that can enable it to actually start informing global governance decisions?

And I mean, in some countries I think you start to see that national health information systems are being built, some innovative use of mobile technology to get information. But I wonder if you're seeing that kind of -- any examples of where robust information about national performance is able to create better national governance of health systems and then inform global governance?

GAYLE: You know, I guess India may be one example where I think the use of information is helping. Some might say Ethiopia may be another example. I don't know. And others may have thoughts on countries where that's happening.

I guess, you know, the -- it goes back to the point that I was making earlier though, that I think governance is not just the structures: I think it's the processes, of which information is one of them. And I think in a world where we are now so much more information enabled, we're not taking advantage of how information can be much more of a driver of forcing mechanisms than it is.

I mean, even just your example that you gave, Arielle (ph), about, you know, how people are spending their resources -- powerful information. You know, but we don't have -- we're not systematically looking at that. And I think there's a lot of ways in which we could be much better if we used information for measures of -- for better coordination, better sharing of experiences but also better accountability that I think then leads to better governance.

And I think some of the structural issues will kind of happen if -- you know, or will be more likely to happen if that information -- use of information was more routine.

I don't know if anybody has thoughts on particular countries or examples.

QUESTIONER: I just have two examples. I remember a couple of years ago when, after Kenya introduced plans to extend universal primary education, they actually had a system where in every single district at the community level, people had information both about the amount of money allocated for the school system there, the amount of money spent on the school system and then the percentage of students who were actually in the school.

And that had a tremendous impact on holding the officials to account --

GAYLE: Yeah.

QUESTIONER: -- when people began to realize that they weren't seeing the money that was supposed to be there.

GAYLE: Right.

QUESTIONER: And then they started asking, well, where did it go?

And then more generally, our results for development -- and Brookings have done a study of -- a project over the last several years in which they've looked at citizen accountability mechanisms in about 39 countries. And the example -- I think this Kenya example was one of them.

Another one that comes to mind was in the Eastern Cape in South Africa. There's a group that's been doing regular studies of the public budgets on health to show, again, you know, what money was supposed to be there and what money actually got used. And that had led to public officials having to really account for their actions and change things that improved -- (off mic).

But that study was published by Brookings last year. And I think it's relevant to this point.

GAYLE: You know, and there have been several countries that have looked at the way resources are spent towards which -- you know, which health conditions and which health conditions actually account for most of the morbidity and mortality, and have seen huge mismatches, which have led to a total reallocation of resources.

And so, you know, I think there are good examples of how just having the information has had a huge impact on shifting the way resources are spent and where, you know, energies get put.

HUANG: Thank you, Dr. Gayle.

(Name inaudible.)

GAYLE: Were you -- sorry, were you going to say something on that?

HUANG: I'm sorry, I -- (off mic).

QUESTIONER: Thanks. Just a quick thing to build -- I'll just say it again, the work on education and other services in Kenya was done by the National Taxpayers Association. And it is a riveting example of what could be for, I think, the fraction of the resources of what -- of what NGOs desired to put in. They basically forced a realignment of government local officials all over who had been, you know, pilfering money, as they have been for decades. And suddenly there were new rules of business. And, you know, some people didn't get it, but a lot of officials just adapted to the new reality. And -- but it took a very strong organization in a country with a strong civil society.

GAYLE: Yeah, and I know when Ngozi Okonjo-Iweala -- who is now at the World Bank -- was finance minister, you know, she did a publishing of public expenditures in Nigeria. And I don't know if that has continued, but it had a huge impact on decreasing corruption, citizens becoming much more active around, you know, advocating for their rights. I think there is this, you know, important value of information, the transparency that comes with it and the accountability.

QUESTIONER: Thank you. Ian Pett from UNICEF.

I think that we should acknowledge that there's been quite a useful, positive trend going on in global governance. It's a lot of complementary organizations and processes. Ann (sp) has already mentioned The Partnership for Maternal, Newborn and Child Health. I'd also cite things such as the Countdown to 2015 and the secretary- general's push to get a global strategy on women's and children's health, which has brought a lot more stakeholders into play with strong commitments.

I think these things are very good, but what I picked up from this meeting that really resonates with my own experience is the dangers of disconnect between global governments and national government processes. But there is one initiative, I think, that is really working on that very successfully. And that's the International Health Partnership. That's brought together a very wide range of stakeholders for something which offers no real financial incentives. It's now more than 24 states. It held its second country health sector teams partners meeting in Brussels in December, at which point it reached 24 countries. Several more have joined since.

And what's interesting about this is that it really does bring the major donor actors, the technical agencies and civil society into play.

And I don't think any other initiative that I'm aware of has done so much for civil society, both with the northern international NGOs but much more importantly with southern NGOs and working out that very thorny issue of representativeness to actually find a way to get this huge nongovernmental constituency actually engaging with a process that would say, OK, we will have representation from some of our number in this process at both global and at country level.

And what's particularly positive now I think is the way that it's playing out in global -- sorry, in country-level compacts where the harmonization and alignment principles from both the Paris and the Accra agenda is now starting to come into play. But there are processes which are being developed globally that are being used. And perhaps the biggest influence of all is that it does seem to be changing behaviors and gives us something where we can look forward to a process and a set of norms in which country and global activity are coming together. So I just wondered if you had any reflections on IHP and what it's meant, perhaps, for CARE?

GAYLE: Yeah, I think -- and it kind of goes back to the comment that Carol (sp) and you made about these specific kind of partnerships and how do they figure in. And, you know, I think we are in some ways moving to a world that says, you know, there are -- there are a few official bodies like, you know, WHO, like UNICEF and others who have large global responsibilities for health and for setting some of the standards and norms. And then there are going to be other ways of bringing nongovernment and the range of actors together around specific issues. And it may be specific in the sense of, you know, whether it's newborns or maternal health or, you know, the other kind of multilateral-ish organizations like GAVI, Global Fund, et cetera, or something that's broader, like the International Health Partnership.

But the whole focus is the partnership, in some ways, and bringing a range of actors together that can both bring into it these different global players but also push out, as a result of what goes on in those meetings, influence what happens in a wide range of actors. And so, you know, I think the International Health Partnership is going to affect a wide range -- you know, organizations like mine and others that whether we're at the table or our -- or our sister organizations are, that also gets fed back to us. And it's -- you know, it's a way for -- you know, kind of bidirectional input into governance. And so I do think that's -- in some ways the way the world is moving in governance is, you know, we'll have the official bodies but then also look at how do we have these partnerships that bring different actors into this and use that as a way of having this kind of bidirectional feedback and input and influence.

HUANG: Thank you, Dr. Gayle. Since we only have five minutes left -- (inaudible) -- collect all the questions. And please keep your questions brief and courteous.

Paul and William (ph).

QUESTIONER: I'll be very brief. I just want to make a pitch for the missing piece of this governance structure that we're talking about being some marketplace dynamic which allocates resources and holds -- and enforces accountability. So to me, the elephant in this room is that people are talking at a very high level here on a global basis, at a conceptual level.

And the reality of the marketplace revolves around money, and it revolves around the mechanisms for the allocation of money. And whereas in the -- in many sectors we have a very evolved marketplace which either brings standards and accountability or an auction framework to allocate resources here, resources are allocated based on either policy initiative or storytelling. And so until we create -- I think, among consumers -- and I'm -- to Emanuel's (sp) point earlier, some sort of economic sovereignty to be able to register some grassroots preferences as well as some standard of accountability, I think we're going to be grappling with this question of what the right governance regime is, because, to me, the thing that's missing in this government regime is the allocation of resources based on local priorities or consumer priorities.

QUESTIONER: I just wanted to bring it back to Haiti and suggest that it is illuminating to look at Haiti. Excuse me, I'm Paul Zintl with Partners in Health and Harvard Medical School. It is illuminating to look at Haiti, because if you sort of look at the extremes -- and there you did not have even before the earthquake a functioning government, and certainly afterwards you did not.

I don't think that means, though, that you do not have strong local presence, and we have good relationships with local government in the regions where we worked in Haiti outside of Port-au-Prince. But even in Port-au-Prince, you can start the process of empowering the governments -- beginning to bring them resources. But you do need to accompany them and start to bridge the gap between the marketplace, the global marketplace, and standards that might be -- that are ordinarily required and what they're used to.

The American Red Cross is working with us now to pay performance- based salaries at the university hospital in Haiti, which has been devastated, but it's the only thing that's kept that hospital open and functioning. There -- you know, it's -- progress is being made on meeting standards, but it is slow. But it doesn't mean that absent a government, we can't do anything. Indeed, we have to.

But to your point, also, the donors likewise have to be flexible, whether or not it's the World Bank or the U.S. government, have to recognize that on that spectrum of government functionality. If they want their money to accomplish something, they have to be as nimble as the NGOs that have to work with the government.

HUANG: Beep. That means time is up. But I think we'll have this last --

QUESTIONER: Hi. I'm Bill Abrams with Trickle Up, and my question very simply is, could you -- what do you recommend as the most constructive, useful role for smaller and medium-sized NGOs, international NGOs, in addressing large-scale problems where clearly there are large actors -- governments, international organizations, large NGOs like CARE and Save (sic)? What's the place for the smaller organization?

GAYLE: Yeah. I'll start and make comments on -- kind of coming around, but I guess -- I think that there's such a huge role for smaller NGOs who might be even more in touch, in some ways, with communities and be able to provide that input and be part of coalitions. I think, you know -- I think we should be doing a better job -- we as -- speaking in the name of, you know, an international NGO -- of linking. We do -- you know, I think we do a good job of working with NGOs, NGO partners in country to do specific tasks, but I don't think we're as good about thinking about how do we use the voices of those NGOs and work more collaboratively on issues like this.

So I -- you know, I just think it's -- you know, it's a call -- to me, it's a call for us thinking about how do we -- you know, how do we organize ourselves better, how do we take advantage of what you're seeing and feed that into the overall system? So, you know, I think we should just all be doing a better job of that, and I think there's a -- you know, there's a huge role, because you are, you know, even more grass-roots in some ways in terms of what you're doing and how you're, you know, working with communities.

You know, Paul, I think you're right, and it's kind of the point several people have made, is that in the absence of a functioning government, there are other organizations that play a huge role, and we should not overlook that and really make sure that we are taking into consideration how to better use and coordinate among the different actors who in some ways are playing the role of government or taking the place of governments, when there's not a functional government. But the risk is that if we're each doing our own thing, then we're only making the task of governance and making decisions and doing things in a -- you know, in a way that is most strategic -- you know, we're not doing that if we're not really looking at how we take advantage of each others' strengths and weaknesses.

And I think the point about the marketplace and how that plays into it is, again -- we talked about it a little bit, that -- thinking about the private sector, but I think also thinking just about market forces and how can that have an impact on, you know, this area; how do we take that into consideration as we look at all the factors that are influencing both what's happening in health, but also what levers we can use to, you know, look at both governance and policies and how we continue to bring about change.

So -- well, I guess we found the answer. (Chuckles.)

(Laughter.) I would just say, I -- you know, I think this is -- for me, it's been very interesting.

You know, you kind of come in having thought through some of these ideas yourselves, but hearing all the different perspectives -- it is a very, very complicated arena.

On the other hand, I think we come out of here with some thoughts about how do we take what we have and do a better job of piecing together the different voices and these different actors in this very complex stage towards a better system but also towards better processes that can bring about a more sane way of looking at global health governance.

So I really -- it's been fun for me to be a part of it, and I've really learned a lot from all the different questions and comments that people have made.

So thanks for inviting me.

HUANG: Well, thank you, Dr. Gayle. It's an honor to have you actually here. And I very much appreciate everyone coming to this roundtable discussion. I'm glad that we had all the questions addressed. It's the first time actually since we launched that series in October. And we'd like to thank again Dr. Gayle for that intellectually stimulating and rewarding discussion. And thank you. (Applause.)

I'd also like to thank Dan (sp), Zoe (sp) and Catherine (sp) for their logistics support in making all that possible. And our next roundtable will be in D.C. on May 12th. We have Larry Gostin scheduled to speak about actually a preview of the World Health Assembly (in May ?). So stay tuned. Thank you.











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