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  • Health Policy and Initiatives
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  • Aging, Youth Bulges, and Population
    Responding to Demographic Trends
    Jess Maurer, executive director of the Maine Council of Aging, discusses demographic trends in Maine and the work of her organization. Jennifer Sciubba, global fellow at the Woodrow Wilson International Center for Scholars, discusses demographic trends and the implications of an aging population at home and abroad. A question-and-answer session follows their opening remarks.  TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations State and Local Officials Webinar Series. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. And CFR takes no institutional positions on matters of policy. Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. Thank you all for being with us today for this discussion. The webinar is on the record. We will circulate the video and transcript and post it on our website after the fact at CFR.org. We are pleased to have with us today Jess Maurer and Jennifer Sciubba to talk about demographic trends. We’ve shared their bios with you, but I’ll give you a few highlights. Dr. Jennifer Sciubba is a global fellow at the Woodrow Wilson Center. She’s an expert on demographic trends and their implications for politics, economics, and social relationships. Previously, she worked for the Hess Center for New Frontiers at the Center for Strategic and International Studies and was a tenured professor at Rhodes College. Dr. Sciubba is the author of 8 Billion and Counting: How Sex, Death, and Migration Shape our World. Jess Mauer is the executive director of the Maine Council on Aging, which she co-founded in 2012. The Maine Council on Aging consists of over 135 organizations, businesses, municipalities, and community members. Its recent achievements include increased pay for direct care workers and increased eligibility for the Medicare Savings Program in Maine. And Ms. Mauer previously worked in the Maine office of the attorney general for nearly two decades. So thank you both for being with us. Jennifer, I thought we could begin with you to give an overview of the global demographic trends you’re seeing and their political, social, and societal, and economic implications. SCIUBBA: Absolutely. Glad to do so. And I have just a few slides to show and tell a little story, if we can pull those up. Perfect. Let’s go to the next one, but it might even—that one might be blank, and it might be the one after that. Perfect. Let’s start there. So pop back one to the star. So let’s think about that.  I love this, the idea of the night sky as a metaphor for understanding global population. Because I remember learning—I had to take one science class in college as an International Studies major. And that one science class was astronomy. And I was so fascinated in learning that when we look at those stars in the night sky, some of them are so far away from us that they don’t even exist anymore by the time their light reaches us here on Earth. And when I think about where we are in this moment of global population trends, I think it’s a lot like that night sky.  In parts of the globe, the human population is already or will soon be shrinking. And that’s really different from what we hear all the time. We hit eight billion globally in November. And Irina mentioned, that’s the title of my most recent book. And we know that we are continuing to see global population grow. But what I don’t think everyone grasps is that while those overall numbers are increasing, there’s a tectonic force underneath that is leading us towards shrinking. It’s kind of like looking at a star that seems to be shining brightly, but in actuality it’s already imploded. And so to understand where we are today in terms of global population, and where we’re going, I want to explain first how we got here. And what I hope you’ll take away from this few minutes that I have to speak with you is thinking about the night sky as representative of our soon-to-be shrinking population is that it is a trap in data analysis. And so I’m actually going to talk about two traps and data analysis and how they relate to demographics, that I think can help us understand how to incorporate demography into our larger planning, which is exactly what I hope you’re all doing at the state and local levels. So let’s go to the next slide, please. Alright, so how did we get here? There are just three ingredients to population change. So that’s all we have to wrap our brains around, and that’s fertility rates. We typically talk about the average number of children born to a woman in her lifetime. Mortality rates. Think about us dying. And, of course, migration. And if we’re at the global level, like the whole planet, migration doesn’t much matter. We don’t have other species coming here yet. But when we zoom down, it matters a lot. And I know to a lot of you on this webinar it matters a great deal for what determines population change at your local level, whether it’s in-migration or out-migration there. So where else did we—how else do we get here, putting these components together, particularly the births and deaths? Next slide, please. A quick overview of our human history in thirty seconds here. It took from all of human history until around the year 1800 for Earth to amass its first one billion people. But as we started to get control over that second variable on that preceding slide, over death, we started to see populations boom. In particular, we were able to help infants and children live to reproductive ages. And that allowed population to boom. If you’ll click one more time you’ll see that it actually boomed from 1.6 billion at the start of the century to 6.1 billion by the century’s end.  And I want to flag this as a moment to understand that probably for everyone on this webinar—maybe a few of you who are in your early twenties not so much—but this is what you were born into, right? I know this is what I was born into. We were born into this context. And when I talked about traps—you know, a little hint about the traps in data analysis, this is one part for us to take stock. What kind of world were you born into? What kind of messages were you receiving about population? We’re going to think about how that colors our view of it. Next slide, please. We’re not just talking about size of the global population. We’re talking about a shift in the composition of the global population as well. So what you see here, they’re commonly called population pyramids because they actually used to all be shaped in this little pyramid, like 1950s, but maybe more accurately called population trees now because they’re actually turning into more of trees. And it’s typically males on the left, in the blue, females on the right in the red. And we see age groups in the ascending order there. So it’s thin at the top in the 1950s. Not a lot of folks living to be over ninety, a hundred years old. And we see that it’s fatter at the bottom. And if you think about where people of reproductive age, particularly women of reproductive age, would be located on that pyramid, and you see that it’s fatter at the bottom, you know that your fertility rate—the average number of children born per woman—was over replacement level. By the time we get to 2023, we now have a total fertility rate globally of 2.3 children per woman on average. And that’s really close to replacement level of 2.1. And where we’re headed is a more tree-like structure. Next slide, please. That mirrors what happens at the country level. And so still today there are countries in the world that do have high fertility rates. In case you thought I was off my rocker in talking about shrinking populations and forgetting about places like Nigeria, or Tanzania, Ethiopia. No, that’s certainly still the case. But there are fewer of them. There are only about eight countries left in the world, out of two hundred, where women have five or more children on average. That is a complete sea change from 1960s, when it was, you know, about 130 countries. So the shape of Turkey’s population today looks a lot like the shape of the global population. And if you’ll click one more time you’ll see that Japan’s population has that tree-like structure, with lots and lots of folks at those older ages and fewer people at the younger ages. So the next slide, we’ll see why that happened. I said there were tectonic forces at work all along. Well, here they are. Since the 1960s, the rate of global population change has been slowing. And so what we end up with, next slide, is that in 1968 lots of women—lots of countries had high fertility. Very few had two or fewer children on average. And now, we click again, and we see that very few have high fertility and that two out of every three people on the planet live somewhere with below replacement fertility. And nearly half the countries that are above replacement, are only just above it, with women having fewer than three children on average. So we’re part of a global trend. And I think this is a spot for us to pause and think about why it matters. And that, you know, we’ll get into this in Q&A because I don’t want to get into Jess’ time, but when we think about priorities, and setting priorities and policy—and I’m at the global level—then we’re thinking about how the interests of those countries that have rapidly aging and potentially shrinking populations might increasingly differ from those that still have very young and growing populations. And it’s just something that I want us to keep at the front of our minds, is how investments and policy priorities might be different in those different settings. But, of course, we all need to be thinking about demography. Next slide. Because if you are thinking about planning for education, care work, et cetera, demography matters. This is just a quick map to show you places where fertility is still higher, which are some of the poorer places on the planet, as you might expect. OK. Next slide. OK, so the first trap is getting stuck in the past in terms of our trends here. So we know that trends change but sometimes our thinking does not change. And so I want to make sure that we understand how much the global situation behind fertility has changed, like those stars. OK, next slide. And, of course, that matters at the state level as well. So state—here, I’m thinking about the United States. And we’re about to make that a very different kind of state. But we—whoops. My own little screen just did something strange. So U.S. population has been, in some ways, exceptional compared to some of its peers for a while. We had relatively higher low fertility, if that makes sense to you. So low could be anywhere from zero to two, right? And we were on that relatively higher end of low. But that’s not necessarily the case anymore, as we’ll see here. And I’m sure some of you—well, probably all of you saw the news coming out of U.S. Census in November and December of last year, that really talked about these changes at the regional and state level in the United States, and which regions are growing or not growing. Next slide, please. That, much like the slide I showed with the little baby and the death and the migration, it’s driven by births, deaths, and migration at the state level as well. So we see here in the United States, our total fertility rate is somewhere around 1.6 to 1.7 children born per woman, on average. That places us, again on that higher—still kind of on that higher end. For comparison, in Japan is probably around 1.3, maybe a little bit lower than that. So this is, you know, kind of typical of a wealthy, industrialized country. And places in the country that it has historically been lower are the Northeast. So we typically see lower fertility rates. This down here is called the general fertility rate. So it’s expressed a different way, which is basically the birth rate—births per one thousand, women fifteen to forty-four. You can see where it’s slightly higher. It’s already, I think, starting to fall again in North Dakota and South Dakota. And, but we see regional differences here. Next slide, please. And we see regional differences in terms of migration. Now, let’s—look, this is taken from the Tax Foundation. So you know that they’re trying to make the point that people are moving to states with lower taxes, but that is true, demographically speaking.  You start to peel down at the level here, and we see people are moving to Texas for jobs and cheaper housing. They’re typically a working-age population. Most of Florida’s growth came from people between the ages of fifty and seventy. So, you know, nuance is always really important with demographics there. So I would submit to you that U.S. exceptionalism is over. We have low fertility. We do have some in-migration that is propping up the size of the population, but the U.S. is facing the same set of issues and opportunities—challenges and opportunities—that other wealthy industrialized countries are. And I think it’s time we wake up to that. Next slide. And we’re almost done.  And then trap two, I just really quickly want to point out that we are all carrying biases in with demographic data. All kinds of ones. Jess has a whole other set of biases besides the ones I’m going to talk about. But it’s really important for us to recognize that. I saw it when I worked at the Pentagon. I saw the U.S.—that line about U.S. demographic exceptionalism, perfect, was talked about all the time. Yeah, you can go to that one. And I say—would often say, we’re not that different from Russia and China. Just look at the little shape of our population here. A lot of things are really similar there. And in fact, if you are a democracy and you need to pivot quickly to deal with an aging population, it is very difficult. If you’re not a democracy, it’s a lot easier.  Next slide. I also often point out that there is a sense in the United States that migration will continue forever, whether you want it to or not. That does not matter to me. It’s just this idea that this—you know, we have the world’s largest stock of migrants in the U.S. So we tend to think global migration is really high. But really, 2 to 4 percent of people live outside the country in which they were born. That’s been true over the last decades and decades. There are actually far more older people worldwide than migrants. If you look at just those ages sixty-five to seventy-four, there are about 200 million more of them than global migrants. So this is a huge segment of the global population and of the U.S. population. But I think we kind of carry some of that bias into looking at the data there as well. And so a question we might ask is, will migration continue at these levels, and for the United States, or not? And last slide for me is just to say—I got two plugs for you here. One is the personal plug. The list of you on this webinar I’m salivating over because I would like to talk to you. Sorry, Irina, but I got to give this plug. My next project, research-wise, is trying to understand how we can thrive, not just survive, economically particularly, in this era of shrinking populations. And so if anybody is talking about this at your state or local level, please shoot me an email or find me for us to chat. And then the other is I’m on the board of the Population Reference Bureau, which does a lot of data and analysis for state and local governments about population projections. And I’m sure that soon—if this is the kind of thing that you’re interested in, I’d be happy to send you their way. Thank you so much. FASKIANOS: Jennifer, thank you so much for that and your wonderful slides. And we will circulate your contact information after the fact as well, in case people did not get it on the—on the slide presentation. So, Jess, now we’re going to over to you with your experience. Talk about what you’re seeing in Maine, what policies you were looking at to prepare there. And I know you’ve been advising other governments as well as the federal government—some national governments and the federal government. So what you were saying and where you see things are working well, and any best practices you can share with the group. MAUER: Sure. And thanks for inviting me. Glad to be here. And I just learned a whole lot from Jennifer. So I’m really excited to be here. And I have questions. And I’m going to be using some of—some of this data as I talk about this stuff in the future. So if whoever is going to share my slides could do that, that would be great. And so you can go right ahead to the next slide. I just thought before we jump into the issues that we’re seeing and some of the solutions, I’d talk a little bit about Maine. So Maine is the oldest state in the country by median age. Our median age is 45.1. We’re also the most rural state, which a lot of people find interesting. And I find that when I talk about rurality, a lot of folks particularly in urban areas don’t really think the same way we do. For instance, I’ve heard people talk about a city of twenty or twenty-five thousand people as rural. So, for reference, I like to say, only nine cities in Maine have a population greater than twenty thousand. And 83 percent of Maine’s five hundred towns have a population of five thousand or less. And, in fact, 44,000—sorry—44 percent of Maine’s population lives in towns with fewer than five thousand people. We have towns, like, with five people in them. And so, you know, we have a lot of rural communities.  We also have the lowest working-age population, which creates a significant challenge. Not just for business, but also when we’re talking about the direct care workforce and a significant growing care gap that we have for populations of all kinds across all settings. So next slide.  So here’s an actual look at our demographics. We have 44 percent of our entire population—entire population—is over the age of fifty. For reference, 18 percent of our population is under eighteen. And 23 percent is over sixty-five. So, this means for the better part of the last decade we’ve had significantly more people every year turning sixty-five than we’ve had babies, and sometimes twice as many for a good three, five, or six years. We had about 24,000 people turning sixty-five and about 12,000 babies born every year. Next slide. So in 2020, we launched a three-year municipal data dashboard project to help communities in Maine understand the challenges that older people in their community might be experiencing, and to take a look at their demographic challenges generally. These were our pilot communities. Just want to say that three of them were remote rural communities. One was our—one of our largest cities. One was a midsized city, and two are sister suburban towns. Next slide, please. So these are two different data points that highlight the differences between rural and urban communities in our—in our community, in our state. One generally looks at the median age. And you can see that, particularly for urban areas, not surprisingly, our median age is lower. But in some of our most rural communities, is very high. So in Eastport, the median age is sixty-one versus forty-five, as a state average. And in that same community, you’ll see that just over 70 percent—70 percent—of the households in that community include a person over the age of sixty. Next slide. So one of the shocking, really, pieces of data that we learned when we started digging deep at a community level was that some communities do better and others do worse at supporting people later in life. So you’ll see here, one community has very few people living in their community who are eighty and older, as opposed to another community which has a much larger percentage. And the next slide is actually the data. And you’ll see that these two communities have essentially the same population of people who are over sixty-five. And so you have to ask yourself, why is one community the community that’s better for older people—which is a city setting, walkable, access to transportation, access to affordable housing—so much better for people over eighty then another, which has no transit, all single-family homes, very few affordable housing units, rural, and very few services? So these are the reasons we start, like, saying, you know, it’s really important for municipalities to look at their own data and not just rely on state and county data to sort of see how they’re doing. I will say, interestingly enough, and why it’s important, this community that I mentioned in the last slide, that has—more than 70 percent of the households have sixty and older, they have a very, very low working-age population. And they said, well, that’s because nobody can afford to live in our city anymore. And they all live outside of our city. So we did a demographic profile of all the communities around their city that they said that older people—that younger people lived in. And the reality is, they don’t live there. They just have a really, really low working-age population, and it’s something that they need to consider. So next slide. In 2022, we did a report on the economic status of older women in Maine. And the next few slides highlight some additional demographic concerns specifically related to older women. On this slide, you’ll see why it’s important to explore data by gender, race, and age. Nationally, eighty—women over eighty have a significantly higher rate of poverty due to—than men—due to gender-based wage disparities across their lifetime. But in comparison to White women, Black women or women of color over the age of eighty experience nearly twice as much poverty as White women. So these are issues we just have to look at, right? I mean, it makes a difference if you’ve just experienced gender-based bias versus gender-based and race-based bias across a lifetime. Next slide. And then to truly understand how folks are doing in your community, you also have to disaggregate data related to age. For instance, all the reports we see show poverty among older people at a rate at about 8 or 9 percent. And we can see here, however, that women over eighty in Maine experience poverty at a rate nearly twice that of men over the age of eighty. So it’s really important not just to say, how well are people over the age of sixty-five doing? But now we have to say, how well are people over the age of eighty doing in our community? And are there demographic differences again, by race, or by age? So next slide, please. So the federal poverty level is the piece that we look at when we say whether or not older people are experiencing poverty. But living alone is a clear demographic issue that has big impact for people later in life. People who live alone when they’re older don’t have a second income, right, to help cover costs, and have no informal care within the home if they need help with care. And they also have no basic help with chores. They have nobody to drive them if they can no longer drive. They have nobody to help them with home maintenance. So two times as many women over the age of sixty in Maine live alone. And women who live alone, not surprisingly, have less income than men who live alone. The next slide, please. So we look at something called the Elder Economic Security Index, which is a national index that tells us how much income an older person or older couple needs to meet their basic needs if they’re in poor condition, poor—good health, poor health, excellent health, and also if they own their own home, with or without a mortgage, or they rent. So you’ll see here, this is both the previous slide and this slide, that at least half of the older women who live alone in Maine do not have enough money to meet their basic needs, regardless of where they live, and regardless of their health status. So these are issues that also help us think about: How we target services? And what do we do, right, when we come up against this sort of issue? So next slide. I just want to say a little bit about some of the policy-level solutions. We’ve been focused on really creating new models of housing in Maine for older people to address the very issue of a community that is no longer working for people over the age of eighty. We asked, well, what can we do? How can we help older people find housing, help older people find transportation? So with our focus on housing, we’ve actually just in the last few months—few weeks, actually, signed a contract with a new organization who’s going to start doing a home-sharing pilot project here in Maine, to get that up and running.  We’ve also been doing a considerable amount of work over the last many years on zoning, specifically related to accessory dwelling units. We’ve had a big win recently on that. And so it’s no longer just town to town whether you could—you can put an accessory dwelling unit or a second home on your property, but now really municipalities have to allow for that accessory dwelling unit. Which is a really terrific thing. We’re looking to implement transportation solutions that really knit together technology that we already have, and we already use, and volunteer driver—volunteer driver programs as well as public transit systems. Trying to make sure that they’re more accessible for everybody and also better funded. We’re also focused, and have been for a decade, on growing the direct-care workforce to meet the increasing support needs of older people. And have had some real success. If you’re—if you’re a direct-care worker in Maine and you’re living alone, you can actually earn a livable wage, which is really terrific. But, you know, not if you’ve got kids or a husband. So we’re still working on cracking that nut. But our big focus has really been on older people themselves and reducing poverty. Our biggest win just came in the last legislative session last year, when we used a lot of the data that’s in this presentation to secure economic justice for older people who’ve experienced a lifetime of economic injustice and disparities, by significantly increasing eligibility for the Medicare Savings Program. It’s a program that puts about $7,500 in the pockets of older people. So this ultimately means that about—well, about thirty thousand people in Maine, older people in Maine, will have more income. And they’ll be more on par with a livable income and will be better able to meet their basic needs.  And this is something any state in the country can do. The Medicare Savings Program is a terrific program. And for those of you who’ve done Medicaid expansion, Medicare eligibility expansion is essentially the corollary. It’s the part that lifts older people in your communities out of poverty. And D.C. actually increased theirs to 300 percent of the federal poverty level. We didn’t go that far. We’re up to 250. So pretty exciting stuff. And but totally doable, to really make a huge difference in the financial security of older people. So next slide. Just a couple more pieces, and then I’ll be done. We’ve also been using this data—and I loved Jennifer’s talking about traps. And I think, you know, we talk about this idea that we’re still sort of stuck in that 1950s thinking about older people, and what they should be doing, right? They should be leaving work. They should be retiring. The reality is, they’re supposed to be dying at seventy, and they’re not. They’re living to a hundred. And, but we really haven’t gotten rid of the views that older people aren’t good workers, that they cost too much money, that they’re not good at technology. And so what we see a lot of is ageism, both at an institutional and a systemic level. And so we’ve been using this data to talk about, you know, these outdated views that older people and aging—that they’re a problem.  And really, this image is what I like to—like, when I think about, you know, for the better part of the last thirty years, we’ve been talking about this, right? A silver tsunami. It’s literally a gray wave of sedentary, medically needy, older people that’s going to crash down on your head and ruin everything. I mean, that’s what we’ve been talking about. And it makes you feel all warm and fuzzy about older people, right? I mean, they’re a problem to be solved. They’re not a solution. So next slide, please. Really, the primary work that we’ve been doing lately is flipping the script, really changing the way we look at this wave. Literally turning the wave upside down, and looking at it as an opportunity. The key here—and I love—I love this point. We’re so focused on in-migration. And we haven’t—we’ve just started to move the needle in increasing the number of people over the age of sixty-five who are working. I mean, we’ve been working on that for a decade. So we’re glad that there’s movement, finally. But the focus has been on getting people to move to Maine.  And so getting this number, this is—you know, there are 200 million more people sixty and over than there are migrants in the world. I mean, that’s a really interesting number. And I’m going to be thinking about how to use that because, you know, we’ve really been looking elsewhere for the solution, when the solution, as we’ve been saying, is sort of right under our nose, that if we are seeing that older people—that people—all people are living longer, healthier lives, and can continue to work long into their seventies, and eighties, even in their nineties, then our solution is right there. But we’ve not yet been able to do that. So we really do need to flip the script and see older people not just as our workers, but also as our volunteers, as our cultural and municipal leaders, stewards of our environment, right? Caregivers for young and old, basically integral parts of our community that we just can’t let go and we need to actually embrace. And then the final slide is a new map. It’s called the new map of life, that’s come out of the University of Stanford. We look at this and it’s basically saying, look, kids are going to—kids born today are going to live to a hundred, by and large. And we have to think differently about our systems. We need to learn differently, right? Space out the way we learn, space out the way we work, and also need to build longevity-ready communities, right? Communities that have these new models of housing, transportation solutions that work for people who can’t drive. Again, not being able to drive didn’t used to be a problem, because people died when they were seventy. Now people stop driving in their eighties and nineties, for many physical reasons. Also just don’t feel comfortable about it. But we just haven’t—we haven’t invested in the solutions that help people move around when they can no longer drive. So we have to do this through this lens of equity. Age equity is what we have been talking about. And need to be intentional about who’s in our communities, who’s being included, who’s being excluded, partner with people in their eighties, nineties, and hundreds to talk about how we design solutions that work for them. We really haven’t been doing this, but it’s really what’s next in relation to, you know, sort of, again, how do we take advantage of what we have and also build what we need to build for the future? So I’ll stop talking there and say thanks for the opportunity. FASKIANOS: Thank you very much. Again, another fantastic presentation. And so we’re going to go to all of you now for your questions and to share what’s happening in your community. As a reminder, we are on the record. So I’m going to take the first written question from Justin Bielinski, who is director of communications in the office of Wisconsin Senator Chris Larson. Do you have any successes from Maine to share regarding increasing density, affordable housing in urban or suburban areas? MAURER: Sorry. We do have some successes. And we passed a really comprehensive—we actually had a committee that worked for a year on recommendations regarding these things and have passed a comprehensive bill in this regard. And I will say, it’s still early days to be talking. So I think the bill—the law itself is a success. But there have been real challenges to implementation. And I’m happy to share a link to that law in the chat. FASKIANOS: Great. And we can also share that out. Next raised hand from Councilmember Jose Trinidad Castaneda. Q: Hi. Good morning. Or, sorry, good afternoon.  So I’ve worked on some of the California ADU legislation. And I’m working on an innovative program for our city, in the city of Buena Park, California. One of the challenges that I have is how do we allocate our Medicare-managed plan funding for ADUs, specifically for categories of our population that are most vulnerable to demographic shifts—employment and economic trends that you were bringing up in both of your presentations? And since we have a silver tsunami right here at home, how do we—how do we balance that, as local policymakers, between what we need in terms of migration, a baby boom, and, like, a long-term kind of stabilization of a very—you know, a massive aging population in our city? So how do we allocate those funds? And how do we balance between those challenges? Thank you. MAURER: And, Jennifer, I don’t know if you—if you have any interest in jumping in. I’m happy to, I just want to— SCIUBBA: I’m listening to this part. Yeah. I’m learning. MAURER: I mean—I’m not going to say that we have it sorted out in Maine, by any stretch of the imagination. And I think the answer is, it’s going to take a lot of different solutions. There’s not one solution that’s going to work, A. And, again, you’re in a very different place than we are, because we’re so rural and we’re so spread out. But one of the things we’ve been talking about, A, is that we don’t ask people what they want. And the things we know that are true is that it’s better for older people to stay in their community. And because we have decided that we have to build—from an economic standpoint, we have to build affordable housing in a certain way or housing with services in a certain way—build and fund in a certain way, we just do. And so that separates people from their community if they, you know, don’t have an affordable housing option in their community. And so, you know, what we’ve been talking about are that we—you know, we really have to build what’s next. We haven’t—we haven’t designed or built that thing, although it’s starting to work. So we—you know, we’ve got a couple of—like, a pocket community in Dover, New Hampshire of, you know, forty small homes, tiny homes. They’re workforce housing, but I think that’s exactly the kind of thing that older people want. And the question is, how do we incentivize the development of the things that people want? I’m not sure I’m answering your question directly, but it’s going to take a mix of doing affordable housing differently. We need some changes within the federal government around Medicare and pairing of—well Medicare, and Medicaid, and also paying for services within housing. And we need to have affordable housing investing in accessory dwelling units and figuring out how to build affordability into them. So I think there’s a lot of solutions. There are a lot of problems that we haven’t found solutions to, but we’re working on them. SCIUBBA: I want to add in a little on that too, because I think what is great about a demographic lens is it lets you see the future in the ways that no other trend does. I mean, there is no other trend where we can be so certain about what the world will look like in twenty years. You know, the people of—the retirees of tomorrow are already born, or they’re sitting in kindergarten desks today. And so we can do this long-term planning. And I’ve even—there’s an architect who looks at age-friendly architecture out of New York City, who’s German, Matthias Hollwich. And he and his firm build modular homes. Imagine being in New York City or in a densely populated area, and when a building is being turned into housing units it’s done so modularly so that it can adjust for: Do you work from home? Do you have two small children? Did your children move out? Do you now have an aging parent move in? And some of this is done in the context of being environmentally sustainable as well.  So, you know, if we build for that, as Jess said, that can look all kinds of different ways depending on the community. In New York, it looks one way. You’re not going to do that kind of thing, you know, in my suburb of Memphis, Tennessee. But there are many options. And I think also, when we start to do an international comparative context, we can learn a lot there as well. Like, we can learn from other states but, like I said, the U.S. has seen itself as demographically exceptional for so long that in many ways we’re way behind. You know, I remember doing some fieldwork in Singapore in 2009. And they were working on complete streets there for older people to get on the buses, and how did they make that age-friendly? And that was, you know, fifteen years ago. So I think there are some places that have aged faster or have been aware of their aging faster that might serve us as models. Yeah. FASKIANOS: Fantastic. Texas Senator Donna Campbell has raised her hand. Q: Hello. Good afternoon. Can you hear me? FASKIANOS: Yes. Q: Yes. My name is Jim Morales. I work policy for Senator Donna Campbell here in Texas.  Thank you, Jennifer, for that presentation earlier. It was very enlightening. And also Jess, as far as the state of Maine. We are taking some good notes here. As you presented earlier, the growing population here in Texas from basically all over the country and other parts of the world. And we are currently working on legislation for the next session that addresses the workforce, especially, like it was mentioned earlier from Jess, as far as the age population—working population. The infrastructure, medical facilities and centers, nursing homes as well for that—in preparation of that longevity. My question is, if you can share, if you have that information, does Maine have any—have data or best practices on nursing homes, preparation for public health emergencies, and natural disasters? Of course, our natural disasters are going to be different from state—from state to state, but there’s some commonalities there, especially when addressing and sustaining our aging population. Thank you. MAURER: Yeah, and I wish—I wish I knew. You know, I don’t do direct advocacy, nor support—I mean, we’re partners with all of the aging services in Maine. But I can certainly find out for you. I know of a lot of our policies, but I don’t know of a specific—or a specific report that would answer that question. But I will find out and be happy to share it with you if I—if I find it. FASKIANOS: Great. One question, how does women’s access to reproductive care influence the population trends that you’ve cited, both globally and domestically? I think, Jennifer, maybe you can start. SCIUBBA: Yeah, sure. I’d be glad to take that. It makes a difference if you have a desired number of children, and you’re able to act on those desires. Certainly, that is why we have seen global fertility fall from, you know, seven children per woman on average to lower. But by the time you get to a wealthy country and how far it is along the demographic transition to lower fertility and mortality, we’re really talking about a lower number of pregnancies generally. So that would be women’s ability to control whether or not they get pregnant. And women have been getting pregnant less, particularly teen women. So in the United States, what a lot of people don’t realize is that that drop to below replacement fertility has really been in large part at the teen level. And so we see fewer teen pregnancies. That is not just from contraception and reproductive health. It’s also from the fact that they are less sexually active than previous generations were. So, you know, it’s always good to look behind those numbers and really see things like, you know, we see increasing pregnancies in my age group, in the forty-plus age group, is actually up. And so it does differ for those different age groups, yes. But having the ability to control who gets pregnant, when, and where does make a difference, of course, as to how many children are born. FASKIANOS: Great. I’m going to Patricia Farrar-Rivas. How are you addressing the high costs of care for individuals with dementia and Alzheimer’s? I think, Jess, you marked that you could answer that. MAURER: Well—I’m not sure that we’re addressing the high cost, but we are trying very specifically to, A, support informal family caregivers. We’ve increased the respite care benefit and have created a respite care program specifically for people with Alzheimer’s and dementia. Are doing a better job of trying to do care coordination. So that is one of the bigger cost drivers in the federal government, or CMS, or—you know, sort of uncoordinated care for people with dementia. We also have just completed the revision of our state plan on Alzheimer’s disease and related dementias, and have a BOLD—the second iteration of the BOLD grant, and are working collaboratively—starting implementation of many of the recommendations of that. And, again, a lot of that talks about coordination of care early, early diagnosis, early connection to services, and then additional training for all kinds of providers. Which I think is really critically important from EMS and Fire and Rescue to local municipal officials needing to understand, you know, sort of how do we—how do we intervene with people who are in our communities, particularly, as I mentioned, right, I mean, women are more likely to live alone than men. And this is a trend not just in Maine, but nationally. And so—and also, we didn’t talk about this, but I think, Jennifer, you bear this out, the generation before—Boomers had 10 percent fewer babies than the generation before it. And so you have a lot of older people who don’t have kids. And so you’ve got a lot of older people with dementia, with moderate dementia, living in the community, and really no supports. And so we’re really talking about, you know, looking at dementia-friendly communities, and how do we integrate some of the good work that’s been done nationally at a local municipal level to put supports in place, both for people living with dementia and with family caregivers. So happy to provide some more support. I’m not sure that we’re—I’m not sure we can say we’re addressing—we’re addressing the cost drivers at a very local level. I’m not sure we can say we’re being successful at the CMS level. FASKIANOS: Thank you. I’m going to go next to Tom Flight, board member in East Hampton Village in New York, with a raised hand. Q: Hi. Good afternoon. And thank you both very much. A fairly straightforward question, which is: What have you found to be the most effective means of educating the public on the changing profile of the population and the services required? SCIUBBA: I’ll add some global part of this. I think that we have a long way to go to get people to understand that this shift towards fewer babies is permanent, and not a problem to be solved. So that is, there’s just a long way to go in getting that. But it is a necessary first step then if we are going to implement these policies and programs that Jess talked about in detail, and all of you are concerned about in detail. It seems to me that without getting that first hurdle—getting over that first hurdle, we don’t plan for the long run.  So that’s why I do always start by putting it in global context. This is not some fluke. This is not an exception. This is a permanent shift, the likes of which we’ve never seen before. But we worked so hard to get there. We worked so hard to get infants and children to live to reproductive ages. We’ve worked so hard to create economic opportunities outside the home, and to educate people and, you know, to thrive. The result of that was having fewer children on average. And so I think we’ve got to—that is a first hurdle, and then understanding how to be resilient and adapt to this is the next step, which I’ll hand over to Jess.  MAURER: Sure. And, you know, I mean, I know this is going to sound ridiculous, but I’m going to say the answer is really just conversation. And we’re hosting those conversations at multiple levels. So we actually have created a thing called the Leadership Exchange on Ageism, which is a fourteen-hour, very intensive peer learning, leadership learning experience. We’ve had 180 leaders graduate through that. And we’re really digging deep on these issues. And what we found, which I don’t—you know, it’s sort of been stunning, actually—is that people—the program itself leads people to take rapid action within their own institutions, systems, and spheres of influence to create some change. It is an aha moment. And so we’ve now taken that. We’re having community conversations. And, again, we are finding them very impactful. People haven’t had a chance to have these conversations. And when you kind of bring cold, hard facts—as Jennifer presented them, and, you know, we talk about them, that people get it and they want to know then, what do we do next? And so, anyway, I will just say, we’re just hosting a series of conversations with employers. Again, helping employers understand why—what are the benefits of a multigenerational—first of all, what’s the business case? And then, what are the benefits of a multigenerational workforce? And if you approach it in that way, and then you give them examples of multigenerational workforces in Maine that are thriving, that are actually attracting workers because of—because they’re multigenerational.  And the ways—that’s the other piece. Is there’s a lens that we talked about, right? When you—when you do things to address challenges—real or perceived, by the way—for older people, older workers, it works for everybody. I’ve heard, you know, it takes longer to train an older worker. And then I say, well, even if that’s true, don’t you think that would benefit younger workers too?  Let’s start there. It’s not true. But even if it were true, wouldn’t it be better for younger workers to have a four-week onboarding process instead of a two-week? And don’t you think they’d probably do better, and feel actually better connected to the organization if you did that? So conversation is the key to this. And I’m going to say it works. I swear it does. So that’s my answer, and I’m sticking to it. FASKIANOS: Great. I’m going to go next to Emily Walker, legislative director in the Office of Pennsylvania Senator Katie Murth. Q: Hi. Thank you guys so much. I’ve learned so much from both of you. I am a Pennsylvania native myself, but I lived in York, Maine, for a long time, and I have family in Dover, Delaware—I’m sorry; Dover, New Hampshire, not Delaware. But, so familiar with the area and the issues that they face. And so it’s very helpful to see the work that you’re doing there. I have a question about kind of tying in sort of the needs of our younger generations into the needs of older generation. You mentioned, you know, more accessibility to affordable housing, more accessible public transportation, and just generally, like, more working—more workplace accommodations as well. Do you think there’s more opportunity that we could be bringing in young—so for being—I’m at the end of the Millennial Generation, and right at the beginning of the Gen Z generation. So I feel like, is there opportunity to kind of build on things that we do need for our aging population, and then the things that our younger generation are also asking for, that they want in their communities? And how can you sort of bridge that together a little better? MAURER: Yeah, I mean, I think that’s work we really have to do. And, yeah, all right, well, I’ll just say it out loud because I feel like, you know, it’s my—it’s my duty to say, you know, I’m not sure generational—like looking at generations are really helpful. Because I think it skews things. What I think is to say, you know, we have older people who need X, Y, and Z. And if you solve that solution—by the way, we have younger people who need X, Y, and Z. As a matter of fact, you know, older people—they’re lonely and isolated. That’s, like, I hear it all the time, like, with pity in your voice. Poor older, lonely people. Well, all of the data suggests that the people who are struggling most with isolation and loneliness are in their twenties and thirties, particularly young people who are going to college right now, because of the pandemic, are really struggling, right? And so, you know, it’s sort of, like, we need to stop talking about age and start talking about what we all want. And what you find, right, is if you look at workers today, right, older workers—oh, they need flexibility, or want flexibility. They want—they don’t want to work forty hours a week. They want to—well, OK, that’s also true for younger workers. I mean, all the trends say it. And so, you know, like, moving to a value-based sort of view, or what do we—what do we—where, where is there common ground, right?  I’ve heard over and over again that people who are described as millennials don’t like to drive, right? They would prefer to be driven. They would prefer to use public transportation. Well, public transportation is what we need. That that wouldn’t be what older people say, but they need—but they need public transportation. That’s what they would say. So for different reasons. So I think it’s like finding commonalities where things work for everybody, regardless of how you come at the problem. We come at the problem through aging, but we always try to solve that problem for everybody. FASKIANOS: There’s a written question from Stuart Murray in the Village of Corrales in New Mexico: It seems this presentation is aimed at higher-density communities. I was raised in a small Oklahoma town where services do not exist. When I talk small, 1,500 people or less. People do lean on other people, churches, et cetera. However, creating these services may not be financially possible. Is this where higher levels of governments need to step in to help these rural communities? MAURER: So I’m sorry if I gave that impression, because, like, all of Maine is rural. We don’t—we have, like—we have, like, nine communities that are not rural. And what we have are—one-hundred-plus communities have started volunteer initiatives called lifelong community initiatives, age-friendly communities, villages, NORCs, whatever you want to call it. We don’t—there’s lots of ones that have no models at all. But these are volunteers within communities that are doing volunteer driver programs, food, lunch programs, home repair initiatives. The key, though—particularly what we found in rural settings—is that you do need some community backbone, some community-based organization backbones. So, for instance, Habitats. And we don’t have Habitats in every community. Well, we also have public housing authorities, but not in every community. So we have some churches—that wanted to—so we look at—from a policy perspective, right, we say we need home repair, right? So the very first—so older people are living in homes that don’t work for them anymore, but we haven’t built the next iteration and we’re not going to build enough affordable housing. So we have to keep people safely in homes. So home modification, and weatherization, and home repair is the—is the first line, right, of keeping people safely at home. So how are you going to get those services affordably? Well, you have to figure out who you have that serves any community. And then we have successfully had Maine Housing then fund those home repair initiatives. Some of them use volunteers. Some of them use public housing authority staff. But it’s about, you know, sort of—we can do this. But it does have to be knitted together through the municipality, through volunteers, and through a community-based organization. We have found, over and over again, different models that work to solve different challenges that people who are living rurally are experiencing. FASKIANOS: Great. I think we have time for one last question. And I’m going to take it from raised hand, Monica Rossman, Glenn County supervisor. Q: Good afternoon. Thank you for letting me ask a question. We live in a very rural county here in California. Population twenty-eight and change. The problem that we’re having right now is getting our seniors to actually take advantage of the services that we are providing, even though it is limited. I keep saying over and over again, in fact I said it during my campaign, you know, a hungry bird only gets fed when it opens its mouth. And if these don’t want to do it, they’re just not going to. And, you know, I’m starting to see all of these programs, which I’m sure, you know, Jess, you could probably agree with me, there are a ton of programs out there. It’s just when they’re not used, they’re forgotten. And, you know, we have a grant for tablets to senior citizens that have been open for two years.  They’re just now, ever since I started—I started peeling an onion, is what I did. When I first got into office, I started taking care of, you know, my senior citizen parents who have Alzheimer’s, dementia, the shared cost, you know, taking care of two households, you know, trying to get two households to run. So my question is, how do we get the—what is the incentive to bring them in? You know, what can we do? That’s the problem that I’m having. And I’m working on it. I feel like I’m going uphill. And I could definitely use some help. So thank you for letting me ask the question. MAURER: Yeah. So, you know, I mean, if I were in a room full of however many people who are here today, I would say how many people like asking for help? And the answer is zero. I mean, like, every once in a while some doctors will raise their hand. I don’t know what that’s all about. But most people really don’t like asking for help. And it’s really true. I mean, like, I mean, I love, you know, it’s a trap, right? Independence is a trap. And what we hear all the time when we ask, when are you old—what’s old and when will you be old, it’s always about what I can’t do for myself. And so there’s a real tension inside of us that says, if I need help, you know, I’m on the—I’m on the downslide here. And so there’s—so one of the things we found that’s really helpful is to ask older people, why is it hard to ask for help and what would help you ask for help? And, specifically, what’s the trusted source? What we heard in my own community when we asked that question is: We don’t want to rely on the same volunteer over and over again. We don’t want to burden our children. We don’t want to, you know, burden our next-door neighbors. But if there was—if we could call the town, or we could call a church, then—and say, I need a ride to the grocery store, that would feel less burdensome for us. So I think it’s about asking the people themselves. And then, I will also say, getting a whole bunch of volunteers, right, together who know about the services to be the bystanders who are there to say: Hey, I know about this great program, when they hear that people are in need of things. And we have found that’s a great way. The final piece, I’ll just say, in my own community, again, we’ve had this—every community has this problem that there are benefits that people don’t want to use. Telling stories in your local paper about people who did use them successfully and how it changed their life is really good. It’s money. It does—it does bring people in. SCIUBBA: Yeah, the two last ones that Jess mentioned, I was thinking come—we have so much research in the public health literature about how to change people’s behavior. And the most effective way being a peer who’s used a service coming into your home and talking about that service. And if we’re talking about family planning, or if we’re talking about old-age services, or, you know, any kind of help in the home, that model just—that community-based model seems to work really, really well. FASKIANOS: Thank you both for this wonderful hour. We really appreciate it, for you taking the time to share your expertise, and for all the great questions and comments. We appreciate you as well. We will send out a link to the webinar recording and transcript, contact information, links to resources. You can follow Jess Mauer at the Maine Council on Aging on X at @mcoaging, and Jennifer Sciubba at @profsciubba. As always, we encourage you to visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they are affecting the United States. And please don’t hesitate to share suggestions for future webinars. You can email us at [email protected]. Again, thanks to Jess, and Jennifer, and to all of you. And we hope you have a good rest of the day. END  
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    Virtual Roundtable: Financing of Primary Health Care and the Central Role and Important Limitations of Capitation
    FRIEDEN: Thanks so much. And thanks for joining us. I'm really looking forward to this discussion. Dr. Kara Hanson has led important work assessing financing in health care. And you might say: Why is financing in health care important? Well, to begin with, health care is a huge part of our economies. In addition, it's a huge part of what determines productivity. So, health and economics are tightly related. For decades, we've been trying to strengthen primary health care. And other than a few countries, we haven't made much progress. What Dr. Hanson and her group have looked at is the essential components of financing and governance. This is really what determines whether primary health care both gets the money it needs and gets the structure it needs to spend that money well. So, spending more and spending better in primary health care. And the emerging consensus is that capitation is of fundamental importance to improving access, quality, financing efficiency. Capitation is the simple approach of saying that a health care system will be paid per patient or family per period of time, whether it's a month or quarter or a year. So, I look forward to learning more. And without further ado–I will say, I didn't do an adequate introduction to Dr. Hanson. But she's very distinguished and has written a series of terrific articles and done very important original work as well as analysis, summary of health care financing. She's really one of the world's top experts in health care financing. So, Kara, over to you. HANSON: Thank you very much, Tom, for that very kind introduction. So, as Tom alluded, I was involved with a group that put together the Lancet Global Health Commission on financing primary health care that was actually published about eighteen months ago. And for–during the last eighteen months, I have been involved in a number of discussions at the global level, at the country level, invited to contribute to national financing strategies. And so, this is a really nice opportunity to share that work and how it's developed and emerged since the commission with this very distinguished group of participants. So, first of all, I just wanted to say a bit about what we mean by primary health care, because even that is contested. So those of you who remember Alma-Ata in the 1970s and Alma-Ata–the follow-up declaration on primary health care in 2018, the primary health care approach is this broad approach to organizing services at the first contact level. In its broadest sense, it is this combination of primary care, as we might know it from North America, the first contact with a health care provider, but it also includes multisectoral action and supportive health. So, the water sanitation sector, the education sector, and it also includes community approaches: the things that we might recognize as community health workers. What I'll say is that our report really did focus on the primary care elements of that. And that's really because that's where the evidence lies. There's just–there's lots of evidence about multisectoral action, about community-based delivery modes, but very little out there in terms of the financing arrangements to facilitate those. That's beginning to develop now, but at the time we were looking at that work there was not much there. So, we really focused on what are the different elements of good ways to finance primary care. Then the next thing we set out to do was understand what's really the challenge. And the challenge–I think we'd recognize from all of our health systems, which is that in general, priority to health is limited. In many countries, governments are spending, you know, two or three percent of GDP on health. It's really not nearly enough to assure universal access to a basic set of services. But within that health budget, hospitals are prioritized over the primary care level. They're much more appealing from a political perspective. They're shiny, they're big, they're equipment–full of shiny equipment, and they're also much more supported by professionals. Right, because your powerful professionals tend to be the highly qualified clinicians who tend to advocate for resources to go to their patch, and there's specialty. So, lots of those political reasons, the primary care level is often really neglected. And I would say that I think we're likely to see that get worse as populations grow richer, grow more exposed to understanding and knowledge about what the possibilities of health care are. There's a real risk that people's expectations drive a further focus on hospital care. So that's something that we really trying to tackle through appropriate financing arrangements for primary care. So, the consequence of those pressures that we have not enough money going to primary health care, that the resources that are allocated to primary health care often don't make it there, they get kind of siphoned off, whether that's through your legitimate or illegitimate means. They often get reallocated when there's shortages at higher levels of the system. And that means that they just don't reach those frontline providers. And then that PHC funding that reaches those frontline providers is–it's fragmented. And I'll come back to that, because I think it's a really important thing in the developing world, this fragmentation of funding flows. But it's also–it's governed by very rigid budget rules that leave providers very limited autonomy to make decisions about where to focus their efforts, and where to use their resources, and how to solve the problems that they're facing. They're on the spot, which all leads to inefficiencies. And so, the main story, I guess, of our commission is that there's, you know, as Tom kindly flagged for you, that countries need to spend more and spend better on primary health care. So that means allocate more money to primary health care, make sure that those allocations are equitable, and that they reach the providers intact, and that they come with well-aligned incentives for providers to be able to manage priorities locally. And those we would say, are all kind of elements of an approach to financing primary health care that's both centered on patients in terms of service delivery and centered on patients in terms of the arrangements for financing. So, what we did in this report was we first conducted a landscaping. We used WHO data to confirm that there are very, very low levels of primary health care spending in the developing world. So, we estimated that governments are spending about three dollars per capita in low-income countries, and sixteen dollars per capita on primary health care in lower-middle-income countries. And we didn't want to do our own price tag exercise, there's lots of those around, I can just tell you that those are orders of magnitude too small to be providing a basic primary care package of services, which at best estimates is probably sixty or seventy dollars per capita. So, we're very, very far away from that. A second finding is that out-of-pocket payments are still really important for primary care. And medicines are a big share of out-of-pocket payments. So those are, those are two problems, right? So, one of them is that we know that out-of-pocket payments–payments that people make at the time they seek care–are a real burden to households, they're not covered by insurance, they have to pay that first dollar. And they have to pay it at a time when they're most vulnerable, when they're actually ill, or someone in their household is ill. And we talk about the impact of these payments as being catastrophic. So, we think about: What is a catastrophic level of payments for a family? It might be if they spend, you know, ten or twenty or thirty percent of their entire household resources on health care in a period of time. And that happens quite frequently. We often associate those kinds of episodes with tertiary care, major surgical interventions, or cancer, really serious conditions. But actually, the evidence is quite clear that the accumulation of small levels of use, like you might find if you had a chronic condition, like hypertension, or diabetes, or a range of other chronic conditions can very quickly get to that catastrophic level. And so, there's lots of good reasons for thinking about where we target our insurance arrangements or our risk sharing arrangements. The other kind of element of this picture was the fact that the level of spending actually matters. So, if you just correlate the level of government health spending on primary health care against coverage of key services, there's a strong positive association. There's no question that spending more buys you better outcomes. What I would say is that the distribution around that scatterplot is quite wide. So, for any given level of spending, there's quite a variety of levels of achievement. And that to me, as an economist, suggests that some countries are making better use of their money than others. And we should be looking at how the financing arrangements can help countries to make better use of the money that they're spending: hence the “spend better” element of our mantra. So, our deliberations as a commission–our commission is made up of policymakers from national governments, it was made from global experts, it was made from representatives of some of the leading global health institutions. And we deliberated over the course of a year, all during COVID. It was a long and drawn-out process made more complex by deliberating at a distance. But what we did over that period of time was work through the three main financing functions. So, we talked about how money is raised for health, how money is allocated for primary health care, and then how it's paid to providers. So, when Tom talked about capitation, which will come to in a moment, but that's one element of the health financing system. So that's one way of moving money from a pool, a bundle, a bucket of money to healthcare providers that carries incentives with it. So, we looked across these three main functions–I won't talk very much about revenue mobilization, I think that there's lots of good reasons why raising money through compulsory insurance or through taxation is the most efficient way to raise money for health. But that's a kind of a different line of argument. What we really focused on was: What are the range of tools that governments have at their disposal for allocating money to primary health care? And we spent an inordinate amount of time thinking about budgets. That might sound a little bit parochial, but actually budgets are really important, budgets are the embodiment of national priorities. And they set out the plumbing and the way that money moves through the system to reach health care providers. So, we talked a lot about the sorts of policy levers that exist both with budget formulation and budget execution, to shape an increase in the share that can go to primary health care. But we also talked quite a lot about service delivery arrangements as a way of shaping financial flows as well. So, one way of thinking about this is, if you have a new way of delivering primary health care, suppose you've got–if you're Turkey, and you develop, for the first time, family doctors, you create a new corridor. That becomes something you've got to budget for, it pulls money just by virtue of being new and shiny, it pulls money to the primary care level. Likewise, if you're a community health worker network in Ethiopia, the creation of that corridor creates an infrastructure that will–is capable of pulling resources out to the primary health care level. And there's this really intimate relationship between financing arrangements and delivery arrangements, because financing can stop delivery from being successful, and it can also enable and facilitate new innovative delivery models. So, if we think about one of the newest innovations that's being discussed in sub-Saharan Africa, is the idea of primary care networks where facilities get together with some shared functions and then some decentralized functions. And that, to the extent that financing arrangements can support that, they can be really important in the success of new models. So, we've talked a lot about budget resource allocation. The next thing we deliberated about was how providers are paid. And in most countries, governments allocate money to a provider through input-based budget. So just a budget that says how much you have to spend on salaries, on drugs, on electricity, on different line items. And that's a–it's quite an easy way of moving money to providers, but it's also very inflexible and allows providers very little autonomy in making decisions about how to configure their services. You could also think about it as funding the supply side rather than funding services. So, just basically funds infrastructure, it doesn't fund services. So, we talked a lot about how you could move from that kind of low-powered incentive structure to one that really captures what we want from primary care. And that's why capitation was such a strong recommendation from the commission. So, capitation is where providers receive a fixed amount per individual that's registered with them per period of time: per quarter or per year. It has four merits, I think. One is that it starts from a principle of equality. So, your starting position is that every person is allocated an equal amount of money. The second is that you can then adjust that for needs. You could say, “Well, in my population that are registered with this provider, there are some that have higher needs than others.” So, if you're–so you can adjust that by risk factors like age or sex. It also is the only payment mechanism that really rewards providers for looking after their populations, for preventing and promoting health. And finally, unlike other payment mechanisms, it gives them a very predictable revenue source over a period of time. So, they're able to plan the resource use and to plan how they're going to configure and deliver their services because they know how much income they're going to have in each quarter. Now, capitation on its own has some problems as well. It can lead to undertreatment, providers can skimp on services. And so, in our pathway to a more strategic way of paying providers, we wanted to have capitation at the core but to supplement or complement that with other provider payment mechanisms where there was a special need. So, if you really had a service that was high priority and not being delivered, you could incentivize it through performance targets and pay for performance. If you were dealing with very remote rural providers, you might provide a basic rural allowance just to cover the fixed costs of being located in a rural area. So, the model we set out was one where you've got capitation at the core of a provider payment system. But all around it, you make use of the best tools you have to deal with some of the downsides of capitation, where we sketched out the class system requirements for a more strategic way of providing–of paying providers. I just want to, before I go on to my last set of points, I just want to comment on fragmentation, because I don't know if there are people in this audience who are involved in some of the big donor agency or global health initiatives that often fund primary care programs in low- and middle-income countries. But one of the consequences of lots of vertical programs and off-budget programs is that providers can often find themselves receiving lots of payments from different sources. And those different sources will often specify a service that they're supposed to pay for, a population they're supposed to pay for, a set of inputs that are only for their programs. And I think this can be very, very difficult for primary care providers to manage. This fragmentation is confusing, doesn't send them strong signals about what's a priority, where should they put their effort. And worse than that, some of the things that we do as a global community to try to address the needs of certain groups is to introduce more of these schemes. So, we introduce a new health insurance scheme for this target group, or we introduce a new vertical program for this problem. We really contribute to this proliferation, and I think that it has really negative consequences for the efficiency with which funds are used at the provider level amongst another whole set of wider consequences. So, two last points. So one is that we also, in our commission, talked a lot about political economy. And we looked at some of the countries that had made some–had some transformations in their health financing systems or their PHC financing systems. And these transformations often arose at a time of a political opportunity, often together with some economic opportunity. But sometimes they arose through some crisis as well. So being savvy to the political landscape and being able to do two things. One is to see politics not just as a constraint, but an opportunity. But also, have your technical strategies ready so that when the political opening happens, you're ready to go. If you've got a political leader who wants a solution to put in their campaign, be ready to go with a well-designed solution, seemed to be a really good way to have a–we called a “politically informed technical strategy”. So where did we land in the end? We ended up trying to describe the attributes of a well-functioning primary health care financing system, and we describe it as having four elements. One is the real importance of having public resources at the core. And so that public resources and pooled schemes, so insurance schemes, social health insurance schemes, or big tax schemes should be covering primary health care first, and that should be the starting point for kind of a gradual, progressive universalism. This idea that pooled funds should cover PHC first is really a recognition of the enormous gains to protecting households from that accumulation of primary health care payments, out-of-pocket payments, especially for drugs that can be impoverishing at the household level. We argued that resources should always be allocated equitably, and that they really need to be protected until they get to providers. That's the beginning of a set of budgetary and public financial management and other guardrails to stop those resources from being diverted from their final destination. And then that these providers should be paid through a system that places capitation at the core, but that also incorporates you know–as systems become more sophisticated, information becomes more widely available –that capitation can then be supplemented with other provider payment mechanisms. We had a few other recommendations that came from the report, they were slightly more prosaic. I think an important one was the idea that primary health care financing is an all-of-government initiative. It means ministers of health negotiating carefully with ministers of finance to show why they need to spend more on primary health care and how they're going to spend it well. But that also within countries–whether you have large, kind of devolved authorities–that it’s important also to be negotiating with those devolved authorities, because that's where those resource allocation decisions are often made. And they're often very difficult to influence from the central level. But I'll stop there. And I'm happy to hear about which bits of that you'd like to carry on discussing further, Tom. FRIEDEN: Great. Well, let me start with some definitional issues. Sometimes I think of your approach as “capitation++”: capitation at the core, but plus for basic infrastructure apparent–especially in rural or urban challenged areas–and plus for well-designed incentives, which we'll get to later. We also sometimes talk of total cost-of-care models, like the ACO models in the U.S. where, in a way, you are less worried about the indicators, because it's harder to cheat, basically. Either someone's hospitalized or not, and if you can incorporate the hospitals in the format, or at least capture savings from prevented hospitalizations, to fund primary care more, you have a win-win, where primary care is preventing more disease, preventing hospitalizations, getting more resources. But capturing that is very challenging and not part of just capitation alone. So, can you talk a little bit about capitation versus total cost-of-care? HANSON: So, I think what you mean by total cost-of-care is that you've got a much greater integration across the primary care and the hospital level. So, in some sense, there's a common budget, shared budget, shared responsibility for spending well, and then a shared gain for managing that well. So, I think that the real essence of that is being is ultimately–the general point is: How do you make sure that your systems at different levels of care aren't fighting against each other, and at best, are all pulling in the same direction? And so, I think that total cost-of-care model offers the opportunity to do that, to present a set of incentives that are about keeping people to be managed at the most appropriate level of care. And to do that, in this case, by if not an organizational integration, certainly by a financial integration across that boundary between primary care and hospital care. So, I think it sounds like–it sounds very promising. I think it also relies on lots of really good organizational arrangements, right? That whole kind of managing of that referral interface is one that just requires, you know, some system strengths and information systems, and then, you know, audit systems as well to make sure that all the promised alignment of incentives is actually paying off. FRIEDEN: Yeah. It's very challenging, because we know for some hospitals, there are unnecessary hospitalizations and there are avoidable hospitalizations. And if you could reduce both of those, you could use some of that money to fund primary health care to avoid those avoidable hospitalizations. But that's not necessarily inherent in the capitation approach. And in many parts of the world–although there are unnecessary and avoidable hospitalizations–there are also many people who need hospitalization who don't get it. So, it's not so clear that you'll have just pure cost saving. HANSON: That’s right, you can't solve it within the system. You need also think about how you use those resources to build improved access to the system. I think also you have to think really carefully about the design of those incentives at the hospital level. We touched very briefly on arrangements that are being piloted in China, where you've got have hospitals being told that they are being directed to support the primary health care level. And that's kind of all fine, except that the fundamental incentives at the hospital level haven't changed. And so, they still are facing, you know, the incentive to draw patients into hospital care and then to over-prescribe medicines and procedures. And so, it's a very–it's a whole system issue, I think, for it to work well. And you can't–these changes in the design system often have unintended consequences. FRIEDEN: That gets us to the political questions. Let's address that for a minute. In the U.S., we have a very good health care system in Kaiser Permanente. And we've had effort after effort to revise our health care system, and it just hasn't been possible to essentially replicate that model nationally. And that model is a total cost-of-care model. They have long term members, and if they prevent hospitalizations, their financial situation is better. In most of the health care system, if we don't prevent hospitalizations, then the health care system has better financing. And as your commission really pointed out, if we want to strengthen primary health care, we have to fix the financial structure of the system. And if we want to do that, we have to fix the politics and governance. So, what are some ways that all of us who work around the world could think about driving political, financing, economic change, to support more and better money for primary health care? HANSON: Oh, Tom, it's like, that's like the million-dollar question, isn't it? I wouldn't–I would never dream of commenting on the politics of your own country's system. I can only imagine that it's one that's got a considerable amount of vested interests that makes it very difficult to budget off its equilibrium, right? Because many actors are really quite comfortable in this system as it is. I think we've looked at the role of social movements. If you look at some of the big changes in Brazil, for example–if you go back, not into the most recent past, but into the mid-2000s–when there was a massive commitment to primary health care, a reformulation of their whole delivery system and a financing system to back that up. That came I think, through a combination of social movements, of favorable macroeconomic consequences, which also made it easier to be at the margins, allocating more to lower levels of care. So, it's a little bit hard to feel a bit–not a bit discouraged now as we look at the real financial and fiscal challenges that many countries are facing and thinking: How can we use that to be a jumping–stepping stone onto a system that is more efficient, and directs people to–seeking care at the lowest possible, the most appropriate level? FRIEDEN: We've seen, you know, Canada apparently strengthened its primary health care system for this reason, they knew as they expanded coverage universally, that they didn't have enough money. And so they made primary health care practitioners the gatekeepers, really, as a way of both improving quality access and controlling costs. HANSON: That gatekeeping function is really important. And I think in the United Kingdom, where I live and work, you know, those GPs are the gatekeepers to the system, you cannot get to see a higher level of care without going through your GP. And I think with the current kind of crises notwithstanding, I think over time it's been shown to be a really effective way of keeping people being managed at the right level. I think it's kind of all slowing down now as the system is under resourced at the macro level. But that gatekeeping function and then the referral function, so how do you facilitate referrals as well. Every country I know has a referral system on paper. Most of them are observed in the breach, right? That people will go first to the level of care they wish to seek care at. And the sort of tools that we've tried to apply–things like bypassing fees, you pay more if you don't go through a referral channel–they don't really deter much use because people are very determined to go where they want to go. What it really does mean is that you end up with the most vulnerable groups not able to afford that bypassing and then being left to the most neglected parts of the health care system. FRIEDEN: I'm going to ask three more questions, then we'll open it up to the audience for any questions they have. The first has to do with incentives within the capitation world. We know that incentives can sometimes result in distortions in the care given or some of them may be fudged. One of the potential approaches for incentives is to have just a start of: Did you see the patients in your panel as a first indicator? Maybe fifty percent in the first year, seventy percent in the second, eighty percent in the third or whatever it is, we're starting from whatever the baseline is. But what are the ways to have reasonable incentives? And related to that, what are the ways to not result in just profusion of paperwork? HANSON: So, I guess I can say a couple of things. One is there's performance indicators and incentives. I think it's worth kind of slightly distinguishing this. So, the performance indicators, what are we measuring in order to reward good performance? And so there is a good question: What are the right indicators to use to measure performance? I think one thing we also note is that providers are–they're pretty candy, right? They respond–they will do what they're paid for. And so–and they're always a little bit ahead of the payers. And so, whatever reward system is there, it needs to be quite nimble and quite easily adjusted, because you basically will–you'll get what you pay for, but what you want will change over time. And so being able to adjust both the performance indicators and the incentives attached to them. So, an easy one is, you know, where do you set your performance threshold, right? If you set it at sixty percent the first year, you know, everyone's going to get pretty close to sixty percent. So, you have to be able to raise it in future years as providers get better able to organize themselves around achieving those targets. So, I guess–so I think carefully is the question. How do you design your incentives and your performance indicators? You just design it really carefully to make sure that you–because they will always have unintended consequences? Always. There's no–there is no perfect incentive scheme, they will always lead to behavior which is, you know, at odds in some way with what you're seeking. The judgment is that that's still better than an alternative, which is maybe an incentive to not do very much at all. FRIEDEN: I guess this, related to that, is the issue of electronic systems, that it's going to be very difficult to have meaningful incentives without reliable digital health care. HANSON: Absolutely. I know when countries have introduced pay-for-performance systems without those digital systems, it has come at an enormous administrative cost, because you have to both–you have to collect the data and then you have to verify the data. And we know from the generation of field studies–field experiments by the World Bank, that the administrative costs of running a pay-for-performance scheme are considerable. So, I think electronic health records are definitely going to be the way things are improved. And we see that–we see amazing things happening now in terms of the digital–the countries that have introduced massive EHR systems–usually, with an expansion of their financial protection scheme. So, the one I'm thinking of is Indonesia. Indonesia has got 250 million people, it's almost the size of the U.S., eighty percent at least now are covered by their social health insurance system. And they have tens of thousands of providers who are billing electronically. And that is creating this–it is creating an electronic infrastructure that allows you to then work with the billing system to set an appropriate set of performance indicators and incentives to meet them. And so, I'm confident that as these large-scale financial protection systems get going, they expand in coverage, that they will help to create the infrastructure that's needed for fine tuning systems. FRIEDEN: Great. Let's talk about prioritization. This, I think, is a real challenge, because in many countries, the idea is we're going to do everything for everyone. And in the lower-income countries, that means de facto rationing, that we won't have medications for you, that we will do a little bit of everything for the people who are very adamant about getting care, but for most people, it's going to be very difficult. Are there examples or are there methodologies to prioritize in a way that is a transparent, inclusive planning process and allows you to say: “For this year, or this term, we're going to focus on these conditions, and we recognize our other priorities, but we're going to get to them next.” I've seen that be very difficult for countries because you want to continue the fiction that we're doing everything for everyone. HANSON: You remind me of what's a very common–so the system for doing that is through cost effectiveness analysis, right? So it is to look at all the interventions that you would wish to provide, to look at the costs, attached to them, the benefits that they generate in terms of DALYs averted or qualities produced and you rank them and you say: “Okay, the first thing we're going to do is take the most cost-effective intervention and deliver it to the entire population that needs it, and we'll see what money's left, and we'll go to the next one.” And so, you sort of go through this ordered set of priorities, where they're ranked by their cost effectiveness. A many, many, many countries have gone through exercises of costing their basic package, basically doing that. So, using cost effectiveness analysis and information on costs and target populations. And it always goes a bit like this: “Okay, so we costed our package, it costs 320 dollars per person, but we've got fifty.” And then, and then the exercise kind of collapses. Where, of course, the answer is to say: “Well do the best job that you can with that fifty.” So, generate the greatest health benefits that are possible with that fifty dollars that you have to spend, so that you are buying–your best buy is you're buying those interventions that will generate you the greatest health gain for every dollar spent. And that is politically painful, right, to actually–because it's the explicitness of that rationing that I think is so painful. And so, countries tend to kind of fudge it a little bit. But that is, of course, how you could take a gradual developmental approach to expanding benefits as resources become more available. So, you can either–once you–so, my colleague WHO, Joe Kutzin sort of calls this a “unified benefits framework” that says if you can figure out the money that you've got, you figure out which populations it's covering, and if you can systematically use incremental money to expand population coverage, and then to expand coverage beyond the primary care level up to higher levels of care, then you can be sure that you are using the resources that you have at your disposal to generate the greatest health impact. But it's politically really hard. And I think it is that explicitness of saying: “Well, I'm sorry, we can't afford this.” I think people would rather fall on other covert methods of rationing, like through waiting lists, or through having to buy your drugs outside the facility. Rather than say, this is actually what our system can afford. FRIEDEN: It's discouraging in part because if systems were upfront about what they can't afford to do, they might be able to get more money from the public and the government. I have one last question–we'll open it up for questions. If there aren't questions, I have five other questions to ask, but raise your hand. If so, we'll come on with instructions in a moment, but just give us a quick sense of what remains to be done, both in terms of what we need to learn and what we need to do to improve financing of primary health care. HANSON: So, I think that the first agenda is that one that you alluded to, when your comments about that total cost of care model. It’s this–the importance of aligning financing arrangements across levels of care. And I think that is, and we looked, while acknowledging the need to align across levels of care, we really focused just on that primary care level. And that's not enough. You can create really distorting incentives by focusing only on one care level. I think there's a really interesting, both a knowledge and implementation agenda around understanding how do you best achieve that smooth transition across this financing–the financing arrangements across those institutional organizational boundaries. Another thing I think we didn't crack and our commission, which I think is really important, is different ways of covering medicines in primary health care. So, in a whole set of countries across the world, at least fifty percent of out-of-pocket payments is on medicines. And it's interesting that the essential drugs world has really not thought about different ways of providing publicly-financed medicines, whether that's through pharmacies with prescriptions and billing centrally, or whether it's through dispensing health facilities, or I think there must be a number of different ways in which this can be done. But there's not a big evidence base on alternative ways of covering medicines through primary health care packages, other than the dispensing health facility, which is the other one that we're probably all quite familiar with. I think the other one that I'm just really stymied by is: What do we do about primary health care providers, particularly about private primary health care providers? So, I'm thinking about places where, in large cities in low- and middle-income countries, where there is a proliferation of partly-qualified, semi-qualified private health care providers that are providing services for payment. Some of those services are dangerous. Often they are really inefficient for patients because patients end up following this trajectory of care, seeking care from lots of different providers, repeating tests, repeating diagnostics, spending a lot more out-of-pocket than they need to. And I think some way of introducing some greater regulation, but also just some kind of rationalization of that healthcare market so that users can navigate it more effectively is really important. And I have not seen good models for managing primary providers at scale. There's lots of experiments, kind of donor-funded projects that show that you can contract private providers to do this or that, but I've not really seen anything that I think can operate at scale across a wide range of health conditions. FRIEDEN: And the answer may be what rich countries have done over the last hundred years: you professionalize, you regulate, and you incorporate into the delivery system. HANSON: Precisely. And what we do know, if you look across the OECD, what's really important in determining whether a country has universal health coverage or not, is the money, right? It's whether–it's public funds. It's not the public or private mix of the provider market. So, you have places like France, where you've got a predominance of private providers, providing primary care and hospital care, and that works just fine. There's lots of different combinations on the provider side that are perfectly well suited in a well-regulated environment with well-managed contracting facilities. But it's really important that the money is public money, because without that, you end up with all kinds of problems of risk selection. FRIEDEN: Great. Let me turn it to CFR just to repeat the instructions for how to raise your hand. And then I will keep asking questions if there aren't any more from the audience. OPERATOR: As a reminder, to ask a question, please click on the raise hand icon on your Zoom window. When you're called on, please accept the unmute now prompt, then proceed with your name and affiliation, followed by your question. If you'd like to view the roster of registered participants for this meeting, please click the link in the Zoom chat. FRIEDEN: So, let's go a little bit further on the issue of PHC supplies. What we see in so many countries is they may be able to hire staff, they may even be able to pay staff, but they often don't have the basics: medications, equipment, maintenance contracts. And that leads to a total lack of confidence and then the leapfrogging to the hospitals. Do you see models that would help address that? HANSON: I think that getting more money into the system, I think that's where the sort of the prioritizing primary health care becomes so important. Often, there's not that much give in the health care worker budget. But there is a need to be able to finance the basics in terms of medical supplies and drugs and equipment. I guess we're talking about lower-middle and middle-income countries, there often is enough money to get their supplies there. In the lowest income countries, I think that's where countries are more likely to be relying on some of the global funds for that. And what's really important is that those resources are moved in ways that don't distort the system. And there's a lot of kind of thinking about how do you–if you do have suitable donor funding for those sorts of supplies: How do you arrange your transition arrangements once countries do get richer to make sure that the benefits of those external funds continue to be that the coverage achieved through those external funds continues to be achieved and sustained without recreating waste, actually? FRIEDEN: Next, you discussed the issue of primary care networks, and we've discussed gatekeeping functions, and the need for referral interface. This is pretty broken in a lot of countries, rich and poor. What are some best practices and ways forward, what's the latest in primary care network development and what works? HANSON: So good questions, not an area that I am totally up to date with. I know there are some interesting experiments going on with new models of care in Ghana and in Kenya, where they are developing these primary care network models and developing the financing arrangements to support them. I think it's probably a little bit too early to say, and I think they are very promising because they offer that–those kind of economies of scale and scope, right? I think if you have those together with some of the kind of newer technologies and opportunities of telemedicine and things that can reduce the burdens of travel on patients, I think there's some good prospects for those models to be very effective in providing better quality primary care. FRIEDEN: That relates to the issue of gatekeeping. How does gatekeeping get to be politically palatable? I think, you know, this idea that we provide everything for everyone and you can go anywhere results in the migration to hospitals. It's not an irrational choice on the part of patients, because hospitals are more likely to have diagnostics, more likely to have skilled staff, more likely to have treatment. And if you need hospitalization, you'll be there. So how could a country that wants to strengthen the gatekeeping function effectively do it? HANSON: Well, there’s two issues. I think one is, unless you increase confidence in your primary care level, then no amount of process is going to stop people from going where they want to go. So, I think it really is an issue of improving the quality and the allocation of resources to the primary care level so that people use–that is the place of choice for most uncomplicated, kind of first line illness. I think the other tool that governments have at their disposal, there are some service design decisions that can be taken in different ways, right? You could–you can choose to locate your HIV testing facilities at the hospital level or at the primary care level. Maybe if you locate them at the lower level, you will still–you’ll be able to both attract resources and equipment and staff to that level, but also keep patients at that level. You know, the alternative, which is to keep investing all of the diagnostic capacity at the hospital level is certain to keep patients flowing up. So, I think that there's got to be some of that kind of decentralization of technical capacity so that people have the confidence to use primary care level first. FRIEDEN: I have one more question, and then we'll turn to Greenberg. To what extent do you think part of the challenge is the disconnect between felt needs and maximum health impact? We see this very starkly in our hypertension treatment programs. Hypertension is asymptomatic. And, a sore shoulder, a bad back, a headache, a toothache, these are all symptomatic conditions. People will go, they will pay for it, whether public or private. But you have to kind of generate demand for immunizations, for example, or deworming, or other things. HANSON: Well, I think yeah, I think this kind of hidden burden of hypertension is a great example, right? So, unless people are using primary care and are routinely being screened, we have–we're going to continue to have this large undiagnosed population of people with a health condition that–without treatment–is going to become very expensive and hard to manage effectively. So, I think there's something about kind of a return to that notion of primary care as a–almost as a family practice, isn't it? As a place where all members of households are welcome and where there is–where there are routine screening programs. And I guess where it is something that's high priority like that, for which there isn't much demand, that's a great candidate for a pay-for-performance system, isn't it? Because that way you can really, you can capture and incentivize the providers to go out and screen people. You capture their efforts is what you want to do. So, you use your pay-for-performance where you think the constraint can be addressed by greater provider effort. FRIEDEN: Great, let's turn to Greenberg. I don't know if–what the salutation is, but over to you. Please introduce yourself and a brief question. Q: Good morning, I really enjoyed this session. Given the disruption that COVID introduced to the entire medical system and created a lot of virtual medicine, what would be the role of a virtual primary care system whereby if a patient needed a specific contact for a physical exam or taking blood pressure, this could be allocated to someone in their neighborhood? How would you see that as playing a role and taking advantage of the disruption of COVID which can be a very powerful stimulus in many ways, good and bad? HANSON: That's a great question. I think that is the big question about COVID, isn't it? Sort of: What do we want to keep and retain in terms of our learning? What were the things that actually, they were good enough at the time, but we need to revert? Here in the UK, there's been some–it's been very interesting discussions about remote consultations for primary care. And a lot of GPs have really, really maxed out on them because they find them a really–a really efficient way of seeing patients and seeing patients quickly. And there is a bit of a backlash for patients who haven't been able to articulate their condition as clearly as others. So as with all of these things, I think they have that sort of virtual consultation backed up by a real consultation is very promising as long as it's well targeted, and I don't know quite–I'm not quite confident that we know enough to be able to target it at those who are best protected by–or to protect people from some of the downsides of it. But it seems–I think it's amazing to be able to see a GP or to talk to GPs. You never used to be able to do that. I can–most my problems I can resolve over the phone. And that ability to do that at my convenience without having to travel into town to go to the practice is fantastic. So, there are clearly lots and lots of possibilities that are opened up by distanced, you know, whether that's, you know, phone or video or otherwise. I think those benefits are even greater if we think about places that have really strong, really big access problems. So, remote areas of the U.S., remote areas of Canada, remote areas of poor countries, to be able to harness those technologies, to bring health care closer to those who need it, I think it's fantastic opportunity. It's just a matter of picking the things that we really want to retain. I would say also and–keeping the thinking also how we keep the adaptations to the financing arrangements that supported them. So, I remember at the very beginning in Canada, having to change their billing system to make virtual consultations eligible for payment. That wasn't–they had to change that so that doctors could be paid for remote consultations. And then that's easy enough to retain once you've got it working. FRIEDEN: And you now have some primary care physicians quite concerned that they may be spending hours on answering patients email questions, and how does that get paid? Another argument for capitation, really. Because you end up having to spend so much effort collecting information rather than providing care. Anthony Yuen? Q: Hi, my name is Anthony Yuen, I'm with the Clinton Health Access Initiative. Really appreciate the talk today. You mentioned the importance of public domestic funding, but I was wondering on the donor side, in your view, what models or examples of bilateral and multilateral development assistance for health would you point to as being most effective in supporting recipient countries’ primary health systems? Thank you. HANSON: That's a great question, Anthony. I was at the Montreux meeting a couple of weeks ago, where I was discussing, yet again, the possibilities of, the equivalent of what we used to call in the old day days, “basket funding”. Basically of, you know, for those governments that are able to plan and then be accountable for their budgets, that surely it makes the most sense to give the money to the government and get them to do your work according to a single plan that's been agreed and to be accountable to a commonly agreed set of indicators. And that works well, where you have a fairly trusting relationship between national governments, their populations–so that you know that the governments are working in the interests of their populations–and where they've developed trusting relationships with their donors. I think you're in a different world where either one of those trusted relationships aren't working. So, if you have a government–and they're often related, right? It's government is not working in the interests of its population, or where the donors are worried about misuse or fungibility in the use of donor funds. So, I suppose there you do have to introduce tighter controls, but as an ideal to work towards I think that's a really important one. And the more that donors can move away from having their own program with their own funding stream with their own indicators with their own monitoring visits, I think the easier it is for governments to focus on delivering the services that they're supposed to be delivering. FRIEDEN: I guess on that issue, I've seen mixed reviews of some of the basket funding initiatives, because sometimes it's very difficult to see the outcomes and the money kind of disappears. And you're not really sure if you've accomplished much. I wonder whether– HANSON: That feels like bad design of your outcome though, doesn't it? So, I think with a well-designed program with indicators that you agree on, and that you can measure, that you can measure, well, then you shouldn't in a sense, you shouldn't care that much how they're produced, right? It shouldn't be–you are effectively contracting on outcomes rather than contracting on inputs. We resort to contracting on input, on how money is actually spent, where we don't understand the production process, or we don't trust the outcome measurement. FRIEDEN: Great. Well, we're coming to the end of our time. Would you like to make a couple of brief comments before I make a couple of comments summarizing some of the key lessons from what I've heard from your wisdom? HANSON: No, I don't think I’ll say very much. Or except, other than I guess maybe just to know one more piece–one piece of work that's following on from the work of the commission is worth–that we're just about to start which, which it's actually it stems from a measurement issue. So, we used in our calculations for the landscaping, we use the Global Health Expenditure Database estimates of primary health care expenditure. And those are all predicated on a common definition of what PHC is across the world. And that common definition of functions doesn't correspond all that well to the actual PHC service delivery platforms in different settings. So–and if you don't have an expenditure figure that's attached to a country-specific model of primary health care, it makes it very difficult for a government to make a commitment: “We're going to increase primary health care expenditure by this much”, and then to be held accountable for that commitment. Because it's not–you need to measure something that is relevant at the local level. So we're just about to embark on a–I think quite an interesting exercise at looking at how those primary health care platforms operate in different types of government settings, whether they're centralized or decentralized, and look at the different ways that are available to capture PHC budgets and expenditure to make that a more useful way of enabling governments to make commitments and then to honor those commitments to increasing their spending on primary health care. FRIEDEN: Great. Well, I've learned and here are seven things that I've learned from this conversation. One, countries are spending way too little. Three dollars or so per capita in low-income, sixteen dollars per capita in low-middle-income versus an estimate of at least sixty or seventy dollars per capita per year that would be needed. Two, that rigid rules are problematic, they make it harder to use even that limited money as effectively as possible. Three, that catastrophic spending–ten to thirty percent of household income–is far too common and a major result of inadequate primary care services. Four, that budgets and other tools are very important. Your budget is your plan. And so, if you put things into the budget, like a new category of health care worker, that gives you some ways forward. Five, that aligning incentives across different levels of care is extremely important, but unfinished business. Six, that electronic systems are going to be very important to allow us to reduce paperwork and look at some of the most important indicators. And seven, that public funding, not public provision, is most predictive of an effective system. And we need to think of regulations, upgrading professionalism and other models to think about upgrading the resources that are going into private health care, because patients are paying often quite a bit for substandard care in many countries. And is there a way to try to bring that into the ambit of a publicly funded system? Kara, any last word for you before we close? HANSON: That was just such a beautiful summary. Thank you very much. FRIEDEN: Well, thank you for the work that you do. Thanks to the audience for your participation. And we look forward to continuing to see how primary health care can get better as the most important–but unfortunately most neglected–aspect of our health care system. Thank you all very much. And we hope that it will not be neglected so much longer, because coming out of COVID, one of the main lessons is: we must have primary health care at the center of our system, or we’ll have less resilient populations and less ability to find and stop outbreaks. So, thank you all very much.
  • Climate Change
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  • Health
    Virtual Roundtable: Moving From Commitment to Action: Improving Primary Health Care
    FRIEDEN: Today we have Dr. Atul Gawande for a roundtable discussion. And Dr. Gawande is currently the Assistant Administrator for Global Health at the US Agency for International Development. He is legendary in the health field, not just a renowned surgeon, but a wonderful writer who has written a series of important and best-selling books on health and health care–one of them, famously, “The Checklist Manifesto”, which really is quite relevant for our conversation today about primary health care and how to make it work for people–as well as a regular writer in the New Yorker magazine. And if I completed at least a partial introduction, it would take up way too much of our time. So just to say that, Atul, really delighted to have you with us today, and looking–really looking forward to the conversation.  We're going to start with your comments on the issue of primary health care. Just to be clear, for almost fifty years, the world has had a commitment to primary health care, and yet, still, outside of Latin America, Thailand, Sri Lanka, very few low and middle-income countries have strong primary health care systems. In fact, the U.S. doesn't have a strong primary health care system. So how are we going to go from the lofty rhetoric that we've had for half a century to people actually having a provider they trust and can access without financial hardship? GAWANDE: Tom, it's great to see you. And thanks for posing the central question right off the bat. I want to frame it by describing what I see as the challenge and the opportunity of global health. We've had a century of discovery that has doubled our lifespan. Essentially, if you're in the top one percent of income, where life expectancy in the United States was mid-forties in 1900, it is now eighty-seven years if you're in the top one percent of United States because you have been able to be the beneficiary of the last century of discoveries that have enabled capabilities in medicine and public health, that if you have access to them, has that enormous effect. Now the challenge is, we have identified seventy thousand different ways the human body can fail, seventy thousand different diagnoses and conditions. We've approved, in the FDA, nineteen thousand drugs, we have four thousand medical and surgical procedures, and north, I count, of a thousand public health interventions that have significant value. And our job has become to deploy these capabilities to the right people in the right way to everybody alive town by town. I've argued this is the most ambitious thing human beings have ever attempted. We are still learning: How do you make it possible to get all of that capability and the most important components of it in the right way in the right time and not bankrupt society, make it and–and reach everybody? And I see primary health care is the center of answering that question.  I can't have this discussion without also saying a little bit about my role at USAID. I have the best–I have the best medical job that most people in health care have never heard of, which is leading global health at USAID. I have twenty-five hundred people in sixty-three offices around the world touching over a hundred countries. We deploy ten billion dollars in aid for advancing our–advancing equity and survival, and also addressing ways to prevent health threats from abroad, threatening global security and national security.  And so, you know, my natural goals coming in, I've been in this job for two years, were focused on, you know, first addressing COVID. Number two, dealing with and preventing pandemic threats. And the third I made advancing primary health care. And why? First was the fact that we've endured the first global reduction in life expectancy during the pandemic since World War II. It has set back core areas of basic public health work. We've seen declines in vaccination of children, sixty-seven million children who've missed vaccinations, declines in basic access to sickness care, rise of infectious diseases, setbacks in our efforts to eradicate polio, and turn TB, malaria and HIV into manageable endemic respiratory illnesses. We've seen declines in health services for maternal and child-health survival. And these are in the low-income countries of the world. But we've seen setbacks and health services in every country in the world.  We have the indirect effects of COVID, of the diversion of resources away from health, economic damage resulting in health budgets slashed, disrupted supply chains for health. And so we've seen development happen in reverse. And we have set a target at–in our program, that with the countries we work with, that we want to see that we're getting to better than pre-pandemic levels of mortality by 2025, just want to see us catch back up to what to the ground we've lost. And so we're tracking the percentage of deaths occurring to people under fifty, as a marker of whether we're getting to the place we want to be. So how do we do that? It's not going to be by going disease by disease and category by category. It's going to be because we recognize that there is a basic scaffolding at the community level, which is primary health care that delivers the vast majority of interventions that most advance our lifespan.  All–virtually all of our work flows through primary health care. Whether it's being, as you've called it, Tom, having an epidemic-ready health system, you know, it's going to be frontline primary health-care workers who are going to recognize when someone has an unusual fever or unusual cause of death, and recognize that the alarm bells have to go up and this needs investigation for a possible pandemic outbreak. But it's also the same people who are doing the vaccinations and doing the child prenatal care and the TB detections and so on.  There is robust evidence that investments that raise coverage levels for the essential services end up decreasing mortality, and that primary health care is in the center of it. I can–we can walk through some of the evidence around it. There's been randomized trials of putting, for example, neighborhood health posts into place in a place like Ghana, where people were trained to a nurse level, not even at the physician level, with outreach workers, community health workers attached to the clinic, who were in sufficient numbers to touch every home at least once every three months in order to do preventive education, assess needs and make sure people are connected into the system, “Oh my gosh, you're pregnant, you need to get into prenatal care”, and be integrated into the next level of primary health care. And the result was within three years, a fifty percent decrease in child mortality, a seventy percent decrease in seven years, a decrease–an increase in the contraceptive use rate enough that the fertility rate dropped by one birth per family. And that impact then was replicated at scale. And this is where it gets super interesting to me.  What we see across countries is the richer you are, the higher your lifespan, and it's like one to one. It's a very tight relationship. But there are a few countries that are positive outliers. And, and you named some of them. Thailand is one where we supported Thailand to build its–build up its health system, meet public health goals. And they did it by building on a primary health-care scaffolding, like the one that's in Ghana, and you know, it got them through addressing malnutrition, and that community support could recognize malnutrition, water and sewage issues, and connect services, but then maternal and child-health survival, and then non communicable diseases. So that today that Thailand with three hundred dollars per person per year for health care achieves the seventy-nine-year life expectancy, which is actually now higher than the United States where we spend thirteen thousand dollars per person per year. You have Portugal, Chile, Costa Rica, Ecuador, Panama, four countries in Latin America that exceed US life expectancy. Chile and Costa Rica have the highest life expectancy in North and South America, tied with Canada. And all with a scaffolding, where there is not just a clinic in a box where a primary-health clinician can be there to provide services, but have this other component of a community health worker, which we will need to talk about, doing outreach to make sure that–in every society there are people who are disconnected from the system–and they are connecting households and families into the system to make sure they have the critical needs met, wherever they are in the life course. I'll note that when we needed to get COVID vaccinations to ninety-five percent or more of the elderly, people over sixty-five, even though we have universal health coverage and insurance, we could not get over three quarters of them covered without hiring what ended up being more than a hundred thousand community health workers who are from communities going in their community, door to door, and offering vaccination, making sure that people were pulled in the system who weren't. And we got to ninety-five percent of people over sixty-five, Republican and Democrat, this was not, this is not partisan in any way.  So how to pivot, how to how to drive to action in PHC. USAID is oriented like many public health programs and the NIH, largely in in terms of these, what we call vertical silos of TB, malaria, maternal and childbirth related care, vaccinations and so on. And that means that you can make enormous advances and not necessarily have built up the strong horizontal health system, a platform that you build on, that scaffolding that I talked about. And so, what we set out to do was learn from what has made those programs successful, establish clear targets for the strengthening of primary health care, focus on a workforce that is enabled at a community level, and collaborate with others: the governments, private sectors in these countries, the civil society, and with other aid sources to make progress.  We launched what we call Primary Impact last fall. In seven countries we made–we chose seven countries that were doing what the WHO’s Director General Tedros had called for which is making a radical reorientation of their health systems towards primary care. And that meant that they were putting a larger percent of their health budgets into primary care. And we were looking for places that had demonstrated that they were making those investments to have more of that community health capacity. Often it was signified by World Bank support, World Bank, you know, seeking loans and development assistance from the World Bank, which is one of the largest–probably the largest source of funding for system-based interventions. They were seeking World Bank funds that were primarily focused on their primary health care system. Often the World Bank is where people turn to for the financing for hospitals, and secondary care, but not enough on the primary health care and these seven countries were. There were five in Africa, so Cote d'Ivoire, Ghana, Malawi, Nigeria, and Kenya, as well as in Asia, in Indonesia and Philippines. And with that, what we aim to do is ensure that where we're supporting HIV programs to get to critical HIV targets, or TB, to get to the targets for elimination of TB, etc., that we were doing it in ways that we're connecting to help build the country primary health system, according to country led plans.  So, for example, in Indonesia, they had started with less than twenty percent of their budget going for health care, going for primary health. They have sought–they have gotten 3.8 billion dollars in loans from the World Bank over the next five years focused on investments in their health system, and they put the primary focus of that on the primary health system. So the result is, already today, they're at thirty-four percent of their budget going to primary care, it’s going to go to fifty percent of their budget going to primary health care. I’ll note we have less than eight percent in the United States going to health care.  And the focus of our support is in five areas. We’re enabling integration of service delivery, so we don't just have a malaria worker or a TB worker but integrated so that they're able to see a variety of conditions and capabilities and increasingly work across the lifespan and not just on children and pregnant women, which is often where we're concentrated, to a broader base of services. Strengthening governments at the subnational level, most primary health care is managed at a local or state level, where there isn't as much expertise in quality improvement, or monitoring the system. Third, around having enterprise digital health systems that enable those workers to be part of the larger digital health system. And then having support for the government in developing their universal health coverage financing systems, their domestic financing approaches, in ways that capture and support their primary health care system, improve the benefit package for primary and preventive care as critical components of that work.  And so our next efforts are in expanding our focus countries in this coming year to a larger group, building out expertise with our health directors in those sixty-three countries–sixty-three country offices. We have joined it with the World Bank in aligning what we're doing especially around something called the Global Finance Facility that brings multilateral donor money into primary health care but has been underfunded. And then also working with other donors. At a country level, we launched something called the Community Health Delivery Partnership, as an effort to move in more lockstep with many countries around the world.  Finally, I'll end by saying there's a kind of reverse opportunity that has been created out of this. There's been, for several years, dashboards around that begin to track how primary health care investments are going. For example, looking at the percentage of health budgets–percentage of budgets going to health and the percentage of health budgets going to primary care. Massachusetts became the first state this year that has put out a state dashboard on the condition of primary health care and they were the ones who demonstrated that less than eight percent of health spending goes to primary health care. Milbank then created the first US dashboard on primary health care this past spring, and HHS is taking the signal from that and going to be coming out with a primary health-care dashboard and strategy. But already just a couple of weeks ago, maybe it's been a month now, CMS, the Medicare-Medicaid program, established billing codes and capacity for community health workers to be paid by Medicare and Medicaid. And those are the things that become dramatic game changers everywhere. So, Tom, back to you on this. Hopefully that got us started. FRIEDEN: Great, really exciting and interesting and wonderful. Let's start with the issue of the balance within the health-care system: to put it bluntly hospitals versus primary health care. There's an over reliance on hospitals that, as I travel around the world, I see it country after country, it's certainly the case in the U.S., and there are multiple reasons for that. Many of the hospitalizations are necessary medically, but unnecessary if there had been good primary health care. But there isn't really a financial incentive to prevent the preventable hospitalizations. And there've been discussions of using total cost of care models or capitation.  What we see though, is this kind of gravitational pull to the hospital and escaping that is going to require more than exhortation. It's going to require, I think, changing the financial incentives within the system. How do you see that happening? We're not opposed to hospitals, hospitals are really important. And there are very many important things for them to do. But we don't want them either gobbling up all of the costs, all the budget of the health-care system so we can't do primary care, or spending so much of their time caring for people who really should or could have been cared for in the primary health-care system. How do we rebalance the hospital situation? GAWANDE: So I promised I would try to give you MSNBC answers and not stories, but of course, a story comes to mind. So Jim Kim, primary physician, became the head of the World Bank–this is now more than a decade ago–comes in and discovers the World Bank is one of the biggest financiers in the world of hospital building. And he's in Hungary, and they tell him, “Our beds are full, we need more–we need more hospitals”. And he's, you know, been asked to approve a country plan that's requested, you know, bigger loans. And he happens to be there on a visit, so he goes into the wards, and he sees that it's full of people. In the ICUs, with people in diabetic crisis, who are being diagnosed for the first time with diabetes, sent out, you know, after days of requiring intensive care to have survived it, given insulin, and told, “This is what you're supposed to do, manage your diabetes”. And there's no primary care to take care of them, and so they bounced back three months later, and then they need to build more hospitals. They had more hospitals in Hungary–already threefold as many hospitals in Hungary as Denmark did. So, you know, with a similar population. And so he was like, “What the hell? How do we ask for requests for primary health care?” And the governments weren't asking for them. And they're, you know, they're guided by what you're asking for.  So there were two things that were critical. Number one was the state and condition and the spending on primary health care was not visible. World Bank started to come up with metrics that say, “Hey, how much of your health budgets are going to health care?” Really important. But then “How much of that budget is going to primary care?” And, you know, the levels–there is no kind of stock level of what it can be, we haven't arrived at a norm. But it's very clear, it's like baking a cake. Survival isn't going to work if you don't have enough of one ingredient versus the other, you just get, you know, something that doesn't–if you're making bread, it's not going to taste like bread. And so, when you're making health, you don't get health, if it's all in the hospital and secondary structure. And investing, you know, in middle and low-income countries, in that primary health base requires going north of thirty percent of budgets, and getting to that place. And when they do, you see these sustained efforts, leading to, you know, these life expectancies that way outshine their income level.  The second thing was they created the Global Finance Facility for women, children, and adolescents. And that was a reward system that said, “If you choose to invest your loan in primary health care, with a focus on starting with elevating your child's survival, and your survival of women and adolescents, there will be an add-on to your loan”, so that you will get essentially, for every dollar–every seven dollars that people get in World Bank loans, now if it's in primary care, you get another dollar that gets added on. And it draws then more interest and has drawn more interest in investment from thirty-six countries now since it was launched in 2015, low-income countries that have directed their loans towards primary health care.  The third is really recognizing that we, as sources of aid for global health, have not sought out the country plan on primary health care and investing in it as part of what we're doing. We focus on whether we're getting the outcomes we're looking for, you know, reduction of HIV rates, or reduction of TB rates, and so on. And often, it is recognized that your best results are if you build that primary care system, but where there are weak primary care systems, we're often building around it with private partners, implementing partners coming in and enabling services because the country systems aren't providing them. And that's not building the long term system. And so that's also something that we track increasingly: how much of our development is going into country-led plans, and that's a critical part of what we have to be doing. FRIEDEN: I would love to ask follow-up questions about that, but moving along. We've talked about community health workers, and they clearly play an essential role. And yet, how do we make sure that a health-care system is supportive of all levels so that the community health worker is supplied, supported, supervised, can connect with higher levels of curative care when needed? Community health workers are a really big part of the solution, but they're not the solution. GAWANDE: That's right. So what is a community health worker? I think of it as two different kinds of people who are providing care at a community level. One is often someone at a nurse level, sometimes below a nurse level, who can be the first point of contact for the care itself and can be trained at levels that provide a wide swath of essential care, before having to leave your community to go to the, you know, emergency room or the hospital level or the secondary care level. But then the second component is the community health promoter. They're often volunteer, but are really vital because they do the home assessments, and provide preventive education, often do vaccinations, provide recognition of stunting and lack of nutrition, etc.  And, you know, Africa has twenty-five percent of the world's global burden of disease, but only four percent of the health workers. Those workers, eighty-five percent of them are unpaid community health volunteers who are, you know, not drawn into the system. So in Africa, we have a severe health worker shortage, and we're not seeing them become paid. Africa CDC has set a goal that there will be two million paid community health workers–health workers in the workforce, and you see–and have rallied heads of state behind those goals. Because this ultimately is a domestic commitment. No amount of foreign aid in the world can enable that to come forward.  So, we are seeing now that's happening. President Ruto in Kenya has committed to paying their 108,000 community health workers. Now they will be salaried, and in fact, are salaried now. In Nigeria, the new president has come in and Muhammad Pate, who used to be at the World Bank working on exactly this project, has committed that their 120,000 community health promoters will now become paid, and they've identified the financing pathway to be able to do that. And then organizations like ours can come in and say, “Well, we'll be happy to support training. We'll be happy to support getting them onto electronic systems. We'll be happy to support ensuring the local governments are better trained to support those workers and those systems that make them successful.” And so you are off and running. And those numbers of, you know, that's part of why we formed the Community Health Delivery Partnership is virtually all countries have had these plans, but have not had support, technical assistance, and visibility, that these are, you know, essential, essentially: the investments that we can come in behind and support even as we can't finance all of it. FRIEDEN: Let's talk about digital health for a minute. My perspective, having traveled to dozens of countries is that largely, digital health interventions have failed. They are often designed in a capital city somewhere they look great on paper. If you look at the U.S., we spent more than ten or thirty billion dollars digitizing healthcare and most doctors hate their electronic health records. In our own work at Resolve to Save Lives, we have shown some success with a deeply user-centric information system that understands the ground realities of connectivity and hardware and other things. But we see a lot of, kind of, false promise and false hopes for what digital systems will do. What's your perspective on how digital systems could strengthen primary health care? GAWANDE: There's lots of complex reasons why doctors hate their computers–or nurses [do] or other folks. They're built for many purposes other than making the care itself easier for a patient and a clinician to navigate. The reality, however, is that as you get electronic systems in, even in a reasonably basic way, they enable transfer of information: a record of a patient that allows you to begin to follow whether it's what vaccines they had, their medical history, their medications, and enabling safer, better outcomes of care. There are a few components that, you know, there's been twenty years of apps being built for here, apps being built for there, and no enterprise system that is actually effective. And what you end up having to build is the digital scaffolding to support the primary health scaffolding in the first place. That digital scaffolding has a few basic components. And what countries have to do is have a digital plan and then a lead who implements that plan.  The plan has to allow for four things to happen. You need an identifier for a patient–for people–that can follow them, that is their identifier, you know, wherever they go in the system. You need to be able to connect different sources of information that that identifier carries with it. You might have gotten immunizations here, a hospital visit there, and end up going for a child delivery in a birth center. And you need the information to be able to be connected to your identifier from those different sources without, you know, being controlled or owned by the government. So it has to have a private connection. The third is a clinician has to be able to receive that information and have access to that system. And they themselves need a smartphone, a tablet or a computer to make that happen.  Once you have that–India is now, in several states, having built systems that enable that kind of function, and you get the ability to layer on top of that, applications that actually work and matter and are updated over time for clinicians to use and have an ecosystem where people are building around this core platform. We don't have that core platform in the United States: a common identifier, a way your information can be connected between spots and a common language and agreement to do that. But you will see now more and more countries that are building on that kind of system. Kenya has established its national digital plan. Indonesia has now done it, India has done it. But you know, we're almost having to go back to basics at this point of making these pieces come together. And then you get to: Here's the intuitive way to track people's blood pressures or the immunization records so that clinicians can enter the system. But it requires that initial scaffolding. FRIEDEN: I want to open it up for the group. But I'll ask you one last question. There's been a long-standing discussion, debate, disagreement between what’s sometimes called selective PHC and comprehensive PHC. With the understanding that we'd really like to provide comprehensive PHC, but since, in many countries, we're not even providing selective PHC, we probably have to start somewhere. Where do you stand on this? And how do you think checklists are relevant for strengthening PHC? And then we'll open it up for questions. So think of your questions, because we'll turn to the group next. GAWANDE: You know, I'm coming in from the outside. I'm a surgeon, so what do I know about primary health care? What I see from visiting all the places that you've been to many more times than I have–even as much as I've gotten to see things–you always start with something that's selective PHC. There's nowhere to start except selectively. You know, in Costa Rica, they started with providing malaria services, nutrition assessment, and some basic vaccinations. And then on top of that, as those workers became more skilled and malaria got almost eliminated, they then expanded to being maternal and child health services and about childhood illnesses. And they were working with a checklist, you know, it's often an integrated management set of algorithms around how you manage the child with a fever, how you manage the prenatal visit, the postnatal visit, and so on, and the services widen. But now, over time, those clinics, each of them have, in Costa Rica, you know, by the year 2000, they had grown to match US life expectancy. And by the mid-2000s, they'd exceeded life expectancy in the United States, which meant that you had to be able to see people who were coming in, who had everything from depression, to diabetes, and hypertension, to geriatric needs. And the capacities were, you know, now they’re physician led with a primary physician–a family physician–have nurses on the team, a pharmacist, and community health promoters who go door to door: they're called EBAIS workers. And they're able to track and assess a very broad range of people's illnesses. It's much more comprehensive. It's never fully comprehensive, and you have things you have to refer up the chain, but they know their communities, they know their needs.  And they in a way we don't–in many countries they set public health goals that, you know, in our community, our biggest killers are, it might be hypertension, it might be cervical cancer and wanting to get HPV vaccination, it might be COVID and they want to get the COVID vaccinations out. But in any given year, they have their goals for the top five killers across the life course. And they're making sure that on those they're getting the ninety plus percent performance, reaching people, not letting anybody fall through the cracks. And that's simply an approach we don't take. FRIEDEN: Thank you. So we'll open it up for questions now. If you have a question, raise your hand or you can, I believe, put it into the chat. If people don't ask questions, I'll keep asking. And you can see the instructions there, you hit the raise hand icon on your Zoom window. While people are asking questions, let me ask you a political question, if I may. The Congress has been willing to fund programs like malaria, TB, HIV. The appetite for funding, primary health care is not very strong. Is that something that you're going to be able to address, especially in this fiscal climate? GAWANDE: So this is so crucial. And it goes back to, you know, we've had fifty years since it was declared that we ought to all be focusing on primary care, but we're not doing it. I totally understand the feeling that if I'm a taxpayer or a congressperson working for the taxpayer, feeling like primary health care is where I pour money into a bucket, and it just comes out the bottom and I don't know what happened here. It should, you know, the critical measure that we're tracking are our essential health service indicators. You know, we should see as a consequence of this work that we're more likely to meet the HIV goals of ninety-five percent of HIV patients getting diagnosed with HIV, ninety-five percent of those folks getting on treatment, and ninety-five percent becoming free of viral load. And it should show that we're meeting the TB markers and meeting the–increasingly closing the contraceptive unmet need. Those indicators that our Congress measures us by should be the ones that we track, and that we're delivering on.  I've added two measures, you've heard me refer to them. One is what are called the UHC Service Indicators. It’s a bundle of fourteen indicators that we should see improving. Those include prenatal measures, immunization measures, TB, HIV, malaria, and health worker density. And we should see that the percentage of deaths that occur in people under fifty go down. And the hypothesis is that when Congress and taxpayers see that for a given set of dollars you're putting into the space, you're getting these outputs then–that will be supported and justified. I see it as not an either-or HIV and primary health care, TB and primary health care, but that we are never going to reach the unmet need and close our goals in these spaces without the scaffolding and it will increase the success of our reach. FRIEDEN: Great. Well, we have a bunch of questions. Let me start with Farzad Mostashari. Farzad? You have to unmute yourself. Q: Hi, good morning. Hi. GAWANDE: Farzad! Q: Hello, hello. This is Farzad Mostashari, currently with Aledade, formerly responsible for doctors hating their EHRs and information not moving where it needs to go as National Coordinator for Health IT. The question I had is actually not about the technology, it's about the financial incentives. You give the example in Hungary where it just makes sense, right? If you're thinking long term, and if you're paying for care directly, for government to be able to do long term planning and say, “We're going to invest more in primary care now and it's going to reduce our acute care costs down the line.” In the U.S., we don't have the central division of care and the government has created a way for private actors to–if they improve primary care–to capture some of the value created in reduced hospitalization and acute care spending. And that's what I'm engaged with currently.  Do you see–on those two sides of the coin, do you see globally, on the government sponsored health care side, what's the barrier to government's thinking long term like that? Is it that they don't really believe that more primary care is going to reduce total cost over the long run? Or is it having a short investment horizon, and then what could be done on that? And then on–where healthcare is privately mostly provided, do you see any other examples of countries that have followed the kind of risk-sharing model that the U.S. has done. GAWANDE: It is true that everywhere, it is hard to convince people to invest in what's going to save lives, you know, ten years, twenty-five years, fifty years, in the long run. There's a study I read about, I think, more than a decade ago, but I was enthralled with, which looked at bridges, and that you could keep bridges alive for a hundred years or more, if you provided maintenance services on those bridges. And every state has its maintenance fund, and every governor raids the maintenance fund in order to build a new bridge, right? So, we are chronically, you know, it shouldn't be that the majority of your spend is in the maintenance fund and the minority is in the building-new-stuff side. And you–there's an optimal level, but you know, on the political horizon, you don't get credit for the bridge that doesn't fall down, you get credit for the bridge that you built, right? And so, everybody's maintenance funds are too low. The way we use–our percentage of spending on maintenance is always lower than we want.  All of that said, what I've seen in the countries that establish this work is that the value–Costa Rica is a nice example because I dug into it, but it's similar in Chile, Thailand and other places, but I know the politics of it better in Costa Rica. When they didn't exist, it was seen as a huge expense. And then they built having a community health-care capability that had a clinician and a visit to your home at least once every three months to assess your needs. And then it got its own momentum that once those places had those services, other places wanted those services. It's like, you know, we don't always invest in schools, but it ultimately pays off to have a school, and communities that have those capabilities want them.  It is also the case that I have seen that those public health–those public platforms with a primary-health structure have been virtually always built on a public government basis, whether it's local, state, or national government building, that core scaffolding. And on top of it, there's always a private sector that people can choose to go to, instead of that system, but that that system was always making sure that people were not falling through the cracks, that there was some outreach. And the public system is rewarded for prevention, is sustained on the basis of what its outputs are for actually making health achieved. Whereas the private sector is almost always rewarded for acute needs and it's very difficult that people don't pay for and tend not to buy expensive insurance for what they do on the preventive side. It's not that it's hopeless.  So, where there are the capitated models, as you talked about, a panel fee or a subscription that you pay, and the Medicare approach with Medicare Advantage, in theory, enables those services to happen. But no one screams about whether, you know, “No one came to me to offer me my COVID vaccine!” They scream about what happens if your acute care didn't follow through, and they sue, and they do all of those kinds of other things. So the, you know, we are always swimming uphill–it's public health–in seeking resources and enabling what pays off in the long run, you know. We don't miss smallpox. We didn't reward any politicians for getting rid of smallpox in the world, but it was a huge payoff. And it's still–I see it as a fundamentally public function with the private sector needing to come in and as far as we can, enabling on the private sector side, support that can, you know, reward and recognize the value that gets paid off.  The fact that in Medicare people can hold on to–tend to hold on to people's households for–or at least families for years of time, does provide some incentive for making sure those private primary needs are met and pay off in the long run. But you know, you're in the middle of that grand experiment and seeing whether it actually ends up translating into more of that prevention. FRIEDEN: We have a bunch of questions. So let's try for crisp questions and crisp answers. Charles Holmes– GAWANDE: The answers have been crisp so far–questions have been crisp so far. I'll work on the answer being crisper. FRIEDEN: Charles?  Q: Thanks so much, Tom. And thanks, Atul. This has been amazing. And thanks for all you're doing too, with Primary Impact and also really trying to leverage the multilateral funding into primary care. Two really click questions. One is, you know, primary care is almost more than anything else entirely–almost entirely workforce dependent. We see so many challenges with government management of their health-care workforces, they tend to have a lot of trouble with performance management, a lot of trouble with the administration and expansion of those groups. As we move towards more of a paid workforce, how can we make sure that we're investing in those performance management systems that have really bedeviled so many of the countries that I interact with? As we try and, you know, expand the roles that the primary health-care workforce can–that management–is really invested in?  Secondly, how can primary health care in this sort of post–so much to COVID vaccination, yet, we're left with so much sort of vaccine hesitancy. We're moving towards more adult and adolescent vaccines like TB vaccines, for instance, in the next few years. How can we–how can primary health care help rebuild that trust to ensure that we do even better next time? Thanks. GAWANDE: I'll try to do this as tightly as I can. So, on performance management in primary care. I mean, we have across the board, it's not exclusive to primary care, secondary care, hospital care, delivering health care is very complex. It involves huge–the amount of coordination and system building that's required is massive. And we're still learning: How do you manage that quality and performance? But we've made huge strides. You know, the more we learn how to measure, how to set targets, goals, that are–that we all aspire to as teams, and the more we function as teams rather than individual actors, the better and better the results we're getting. And, you know, it's the slow, as I said, it's a generational problem. It's not a one-time fix, it is mastering that art.  What I will say, however, is for all of the difficulties, you know, Chile has people in the streets just a few months ago, complaining about the quality of their primary health care and wanting to see, you know, better–significant improvements. And they–with a fraction of our income, less than less than a quarter of our income per capita–are achieving an eighty-two-year life expectancy. And so, you know, it's not that we have to get it perfect, it is within reach to make sure that these essential services are there. And the critical component is being able to say that we actually have goals for our primary-health clinics that they should be achieving: getting to ninety percent of the high blood pressure recognized and delivered on cardiovascular disease, the biggest killer that we, you know, as one example, that Tom works very, very hard on. And in the United States, you know, we're barely past fifty percent of us–we don't set a goal. There is no goal that we, you know, we have a cure for Hepatitis B and C, and we have not figured out how to set a goal that we're going to make sure every one of our communities or clinics are oriented towards making sure that that is addressed or that the blood pressure is measured and managed. So that ability to have goal setting, to track it at the primary-health level and marry it to public-health goals, is what many places are doing and what we need more places to be able to do. FRIEDEN: Thank you– GAWANDE: Oh, and then, there was, on the vaccine hesitancy. I'll just say, you know, the more we move past the politicized moment, the better–the better off we'll be. You know, early on, HPV vaccination was really–there was a significant political divide about each vaccination against cervical cancer. And then, you know, the heat was turned down, it was pulled out of the headlines. People, you know, moved on to the next social cultural war. And we've quietly gotten past eighty percent of our adolescent girls vaccinated and dramatic drops in cervical cancer.  You know, Australia, which is–which has similar rates, slightly higher, is starting to see that they can set a goal of eliminating cervical cancer, of the types covered by the vaccine. So there, vaccine hesitancy, I think happens, is addressed at the community level with community health systems, primary health systems, that approach people, talk to them about the facts of what's on offer to save their life. And we see again and again in those settings, if we can make sure that that system is what people have access to, they deliver real results. FRIEDEN: Great. Next question is from Kyla Laserson. Q: Hi, thanks. This is Kayla Laserson from CDC– GAWANDE: Hi, Kayla! Q: Hi. Thanks so much for this, this is great. Just a question about what your thinking is on–especially globally–diagnostics at the primary health-care level, especially for acute febrile illness and partnership with the private sector for that? GAWANDE: Well, so this is where I get to plug one of the things I've been very excited about. I mean, first of all, we're moving diagnostic capabilities like molecular diagnostics to diagnose TB and other conditions, increasingly becoming something that can be done at the primary health-care level. You know, it used to be these genetic–diagnostics can only be done in national labs. Now it can be, you know, we have increasingly portable handheld less than ten dollars a test capacity and that price is dropping.  But what's exciting to me is we're seeing other tools also land. I'm rolling out in seven countries, in our TB program, AI based chest X ray detection systems where you have, on a laptop, a AI based program that will read digital, portable chest X rays that can be done with a–with a system no larger than a backpack, that are deployed at primary health-care levels in Nigeria, in Vietnam, in a variety of other settings. In Nigeria, the combination of a chest X ray, you can do at the primary health care level to screen people or look into whether a pneumonia is present with a molecular diagnostic has contributed to a forty percent jump in the number of TB diagnoses made in the last year. So, I think we have an increasing variety of tools–we're going to be testing out AI based ultrasound for pregnancy as well–that move capabilities that formerly required really high-level radiologists and technologists to have those tools be more and more available at the bedside level. FRIEDEN: Great, thank you. Next, Tom Bollyky. Q: Hi. Thanks so much to Tom and to Atul for this great conversation. I'm Tom Bollyky, I direct the global health program here at the Council on Foreign Relations. Atul, a question I had is obviously we're coming out of the pandemic, many countries are struggling with debt. On one hand, this would seem like a particularly inopportune moment to try to advance this agenda. But there is another way of looking at it. And I wonder how much the conversation around primary health is being seen as part of the discussion of how to have that fiscal restructuring in countries, how to have policies that are more sustainable and more conducive to their debt levels, and to the degree to which you are working with our multilateral bank partners or treasury on those issues? GAWANDE: Yeah, so you know, they have been, I would say they're only loosely connected. The connection that I see–so as you're pointing out, debt levels after the pandemic have risen enormously. A lot of that debt is held by China and by European bond markets. And for health systems in low-income countries, that means you don't have cash to buy pharmaceuticals, to buy vaccines, to buy fuel for getting health workers out. And so, it's devastating for health systems.  And the biggest challenges around trying to get China and public markets to recognize that that needs to be restructured. You need to, you know, expect now that the countries are simply not in ability–don't have an ability to pay, to pay it off and retire some of that debt. But we're not getting there yet. When you're having to do with less fiscal space, because you see countries like Kenya, for example where the budgets, the amount of budget, the majority of the federal budget now is going for debt payment. In a tighter fiscal space, there's a strong case to be made that your top priority has to be primary health care. And coming out of the pandemic, the disruptions in the primary health-care delivery, you know, simply not being able to provide pregnancy services and other things like that are making it critical to have choices that address these primary health needs.  So, it's an indirect effect, it is hard, you know, when you're, as Tom said, when you're facing off budgets for hospitals with urban environments that have more political clout often, and the more dispersed community health needs of a primary health sector. However, a dollar goes so far in this setting, that being able to get a hundred-thousand workers paid in Kenya at relatively low costs, because they're your lowest cost health worker cadre was politically salient, very powerful and important in Kenya, given that they wanted a win in a tightened fiscal environment. As a way to address the debt crisis, it doesn't help provide a pathway out from a situation where the costs of debt are outpacing your growth in your economy and your tax receipts. FRIEDEN: Paying the health workers is one thing. Supplying them may be something else. Jordan Kassalow. Q: Yes, thank you, Tom. As the mortality and morbidity burden moves from infectious disease more to the non-communicable diseases, like hypertension, cardiovascular disease, diabetes, one of the challenges that we see is that many of these top killers are asymptomatic, whereas from my experience working in particularly under resourced places, what drives people into the health system are things that are visceral. And the most common visceral problems to the human being tends to be oral health issues, ocular health and or vision issues, auditory issues. And the problem is those areas have not gotten any, any leverage, any– FRIEDEN: I’m just going to interrupt because we're just about at time. So we have time for a quick question and quick response. Q: The question becomes, how can we leverage these visceral issues that are so common, to both solve those problems themselves, but also to help drive people into the primary health-care system and get them the things that they need for the killers? GAWANDE: Okay, well, two quick things. Number one is the majority of deaths in Africa are still in many of the common public health areas of focus, HIV, TB, maternal child health, malaria. And so–but we've got now a large space that has come for cardiovascular disease and coming when you had the chest pain is way too late. So completely agree. There is–if we go to Asia or Latin America, where we have advanced to the point where those systems are now treating people across the life course, where the infectious disease burden has become quite low. That is, in fact, what they're adapting to do. The needs that they're being called upon to address may be oral, they might maybe eyes, they may be geriatric needs. You know, and they've built out and trained more geriatricians per capita in Costa Rica than the United States has, as a result at that primary health level. So, you do become demand driven. You get people in the door for what they–for the ways in which they feel badly. And then you attach to that your preventive needs to make sure that their care gets to doing–gets to the goals we have for the longer run. Tom, this has been really great as a discussion. I appreciate you inviting me. FRIEDEN: Thank you so much. I’m sorry that we didn’t get through all of the questions, but thank you so much, Atul and thanks for the great questions. It's a great discussion, it's a crucially important topic, and I'm just hoping the coming months and years see lots of progress in lots of countries so thank you so much.
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