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Refreshments. Dr Taylor is head of the Global Child Health Program at the Royal College of Pediatrics and Child Health. He is the member of the who technical advisory group on polio eradication in Afghanistan and Pakistan and was a senior research fellow with the who commission on social determinants of health. He has served as chief executive to two international humanitarian NGO S the International Rescue Committee and landmine Action. Hello. Um Yeah, on the top. Uh so you came back I II get my clothes. Oh, of course you want to do. Yes. Yes. Yes, I'm, I'm, I'm gonna, you can travel as much as you move around around there. Very good. All right. Um So yeah, I'm Seb Taylor. I work at the Royal College of Pediatrics. Uh I do some work with the World Health Organization. My background is mainly global uh health policy with the social determinants of health Commission and health systems development, primarily in low income and fragile states. Um I'm slightly concerned about two things. Uh One of which is that somebody's gonna die over the next 45 minutes as a result of the temperature in the room and I'll be held responsible some in some form, but I think they've got some artificial air coming in now. So, so, so that, that should help. The second thing is there's a sort of cognitive dissonance, I think between hot topics in global health and the other pedestrian title that I've, that I've come up with a critical role of secondary care yet. What I'm hoping to do over the next 40 or so minutes, about 35 if I can do it quickly is to persuade you that secondary care in low income, particularly but low and low middle income countries is a very important thing. And I think, you know, we heard a little bit about that at the start of the day. It's not necessarily being approached in the most rational fashion when we think about global health and let it pause just for a moment. I'm going to stop moving. We need to think a little bit about what we mean by global health because it gets talked about an awful lot. It's a very big thing now in, in global policy circles, everybody talks about global health. But the question that I think you should be asking yourselves is, are we all meaning the same thing? I was at ABM J conference a few years ago on global health and I was so annoyed by the end of it that I wrote a paper, obviously, that's what people do when they're radically annoyed and I forgot to change the title from the working title, which was Global Health. Meaning what? And that then became the title of the paper. But it is a question we need to ask, what is Global Health? What does it mean? What does it entail? What does it allow us to do? And what does it mean we have to do? Because if you take just the example of global health security after the pandemic, what you can see in the way in which the pandemic treaty is being negotiated right now is that there are very strong interests in high income countries to protect their economic interests around the world rather than disseminate expertise to protect people more generally. So again, I think this question about what we mean by global health is a, is a pretty big open question right now. That's not a very helpful thing to say at the beginning of this conference. But there it is, oh, by the way, well done, it's a really good conference. OK. So uh lots of progress just out of just out of it. But if anybody wants to chip in from the, from the side, as long as it's not, you know, overt heckling do um what do people think? I mean 2024 global health, fantastic triumph or, or bit of an issue. Any thoughts, any votes, either way? Yes, an issue. So disparities between high income and low income countries is still there possibly exacerbated by the, by the pandemic. I'm not gonna say the word COVID or COVID cos I can't pronounce it. I don't know which way it goes. COVID COVID anyway. Yes. I think that's true for me. Still issues and I want to talk about that. Now, I think people sometimes feel it convenient to peg those continuing issues to the pandemic and that's a bit of a falsification because those issues were there well, before the pandemic, they still are. The pandemic just got in the way. Ok. But lots and lots of progress, right? These are the main things that kill babies and Children. I think we're all familiar with this. I'm not gonna stop on it. And what's interesting to load is around the side and you can't read this cos the slides are too small. But uh in infectious diseases, for example, between 19 92,017, you've seen something like a 60% drop in mortality associated with infectious disease, right? For neonatal conditions, it's something closer to about 25 or 30%. So, so differential in terms of speed but overall progress and we see lots of people in Geneva and New York patting themselves on the back and thinking well, good job. But, but I think what we need to remind ourselves is this job is at least not done and probably still quite challenging in terms of how we approach it. So this is World Bank data on low middle income and high income countries around uh undefined mortality. The reason I show you this bit apart from to demonstrate my skills and powerpoint is, is is this kind of deceleration trajectory, right? Anybody seen this before? I imagine you will have done in various places. One question is whether it is the reflection of a few bad apples, a few really poor performing places or whether it's something more systemic. And so if we were to look, look at Sierra Leone from 2010, all the way through here, we have under five infant with neonatal mortality. We see that really quite sharp deceleration around the beginning of the last full decade. Sierra Leone, we know is a very challenged place. We spend quite a lot of time in the college working there and and resources are certainly scarce on the ground. Again, it goes back to the things you were saying earlier on today. Uh but this is uh Nepal and over the last five year period of the demographic health survey, you see a flat line in the va mortality reduction and the Nepali government is extremely exercise about this. I was in Nepal late last year and this is something which is bothering them a lot. And then we look at Bangladesh, Bangladesh actually a bit of a poster child for some, for some health intervention over the last 20 years, we're still seeing that slowing down trajectory. So what I'm saying is I think this is not just a few bad apples. I think there's something systemic going on and I think we need to consider what that, what that might be. Well, notwithstanding that we've reduced under five mortality by about 55 56% over the last 34 years. You're still seeing a very large number of mothers and babies die of avoidable causes. This is maternal mortality. Uh and look at the purple part for um this is Saran Africa, right? So quite good global progress, but what you're seeing regionally is something a little bit different. There's a lot of stubborn mortality going on in southern Africa, which is not being effectively addressed. And I think you could probably make the same argument for certain parts of South Asia as well. If you look at um neonatal mortality, 2000 there to 2018 on the other side. And some of the principal drivers of neonatal mortality on a global footing. These data come from who we're seeing prematurity. We're seeing congenital conditions and we're seeing sepsis again, relatively slow progress on those issues. So I think the net of all this for me is that over the last 25 or 30 years, you've seen a very significant amount of global investment in community and primary levels of care. You've seen lots and lots of investment in big vertical infectious disease control programs. What I think you've seen less of is really solid, rational investment in the health systems that underpin those kinds of activities in the countries that we're talking about. And I think one of the reflections of that is you've effectively had the bite of the cherry, you're gonna get in terms of those mild to moderate malarias, those kinds of solvable conditions in the community and primary setting. And the more residual parts of complicated pregnancies, obstructed labor, newborns who are premature or require a bit of extra care and that requires secondary intervention. It's not there, it's not in place that I think accounts for a certain proportion, if not a large proportion of that slowing down. So in 2017, wh O which as you know, is nothing is not brilliant in every respect. I truth be told, I love wh o but we know it's a bit bureaucratic sometimes. Anyway, they were worried by these, these the, these, these dynamics and so they went and had a look at what was happening, not a large proportion of that slowing down. So in 2017, wh O which as you know, is nothing is not brilliant in every respect. I it truth be told, I love wh o but we know it's a bit bureaucratic sometimes. Anyway, they were worried by these, these, the, these, these dynamics and so they went and had a look at what was happening to IM NCI. You're familiar with IM NCI integrated management of newborn and child illnesses. It's a it's a training package which has been in place for a number of years in most low and middle income countries is supposed to improve primary level care. And on the whole, it's done a pretty good job. What they found in their global assessment of IM NCI is that it's the lack of back up in the secondary level that limits the efficacy of that investment in the primary level. Ok. So what they looked at there was improvement in quality of care in secondary facilities. And as you know, from around 2018 19, wh O launched a new uh global quality of care initiative, familiar with this, just another thing to read. Uh It's an interesting document, to be honest, I think they've got about 10 countries signed up. Uh So it's, it's, it's struggling to make headway, but it, it kind of tells you about where the policy would like to move and what is happening on the ground in terms of the barriers to make that a reality. One of the things that, that that has been found is that quite a lot of quality of care initiatives are just fragmented. They're kind of little bit here and there. They're silent within a particular area of, of, of specialism or they are confined to say a six or 12 month period. I mean, the number of and you will have seen this, the number of times you see a quality improvement initiative in a facility, looking at hand washing over six months, you do an audit at the start, you do an audit at the beginning, everything looks better at the end and you walk away the next year. Of course, the water company turns the water off a and suddenly we're back to uh, close to zero. So, one of the concerns that we have had is that is a lot of the intervention we talked about this earlier again is coming in from the outside. It's not a adapted and fitted to local circumstances and it certainly doesn't reflect the resource base which is available in those kinds of settings. And the net of all that is that it doesn't tend to have much in the way of fraction, we know that countries are developing plans. But actually what we're seeing is that those plans are not being populated with genuine resource availability. So I'm gonna talk briefly about what the college has been doing and I want to say this to start, the college is a very small player in this whole thing. Uh We're a small team, the college is mainly UK focusing, not sure the college senior administration know what we do. I just think they think it's kind of interesting that we should probably get on and do it. But it's a really small contribution. What I think is really exciting about a room full of people like this. However, is that through that kind of small aperture there is a lot of capacity in the UK which could be distributed more equitably around the world in ways which are genuinely supportive of what other people are trying to do. And so one of the things I hope coming out of a meeting like this is that you guys are, are starting to think. So what is my role in that? What would it look like? Um I might, might, might, well, I'll come back to that later. So what would it look like? So us over the last few years, generally speaking, our determination was to focus on secondary care. Why? Because we don't have the scale for primary and community levels and, and, and furthermore, we're not the best fit organization to do that. There are lots of other organizations say the Children UNICEF and so on and so forth. We do really good work in that space. Plus the primary care setting itself is, is a pretty complex one equally. If we were simply to confine ourselves to working at guideline level in the tertiary er facilities, we wouldn't be touching much of what's going on in most of the countries we're interested in working in. So the secondary level was kind of where, what the college can offer and what the needs look like had had best for. Does that make sense? I'm hoping that makes sense if it doesn't make sense, this whole thing is for not. Ok. So outreach obviously, and one thing we've found is that increasingly we are being asked by government with, with whom we work, for example, in Rwanda to, to, to stretch out into the primary level mainly because, well, I'll talk about it in a minute, mainly because quite a lot of what happens in terms of an antenatal care and intrapartum care is happening in the primary level and effectively shapes what is possible to do. And secondly, so there's got to be some out which we just have to work out how big that is equally in most of the places we work. We have been encouraged by government by UNICEF by other partners to expand our focus from the quote unquote pediatric to the multidisciplinary, in particular thinking about moving backwards into neonates and then into obstetrics and delivery. And that creates all sorts of institutional. I'll call them dynamics for the time being. Uh But I think there are challenges around trying to get a more joined up process between the delivery side of the hospital and what's happening in the neonatal unit. And this is something which is not just clinical. Uh II hate to say this because your main clinic I suspect but quite a lot of the change that needs to happen is nonclinical, quite a lot of what needs to happen in hospitals and around hospitals. And in the policy environment doesn't depend entirely on clinical, it depends on political, it it depends on anthropological, it depends on diplomatic, those kinds of skills, what I would say. And one of the reasons I quite like working at a royal college is that I've seen lots and lots of interventions, which doesn't have much in the way of clinical back up to it in public health, for example, and it can be relatively weak. And I've seen lots of clinical intervention which doesn't have a social context and that can be weak when you get the two together. That's when I think you start to see some real uh some real strength. OK. Uh So I think it's a pointer. Is it a pointer? No, I just turned it off. Oh, I just turned it back on again. That's, that's brilliant. Uh Hang on. II was gonna, I was gonna point something but no, no. So you got uh in here. But if you're not working in maternity, you're not dealing with half of the problems. You're about to see if you're not working with a A and C room which is small and in a cupboard on one side and nobody really wants to sit in there. You're not gonna get quality A and C, you're not working with infection control sepsis in the neonate can get, it is not gonna go down. You're not working with pharmacy and suppliers, you're gonna find that Oxytocin which was available in your last audit suddenly isn't available this time then. So you've gotta do the whole thing and that is challenging from a resource point of view. And it's challenging from a local politics point of view. And it's challenging from persuading institutional actors to get together and collaborate. Uh And we talked earlier about not parachuting in people from the outside. This is a big deal for us for quite a while. In its early years, the colleagues much like other actors uh were bringing in commissions from the outside on a volunteer basis. I think those volunteers actually just wanted to say, I think volunteers can be extremely helpful in stimulating change. But the way you get sustainable change is through working with local clinicians who have a vested interest because they work in these places. And so these are the guys that in the round of that work with us. And they're the ones who develop the hospital improvement plan where each three months they look at performance data, they pick out areas where they feel data are showing gaps and then they focus on strategies to fill those, fill those gaps. And that hospital improvement plan is now has now been going on for in ran them for about 4.5 years. So it's not just a short run thing. This is a continuous part of what the hospital uh aims to do. And of course, we cover all the continuum from, from delivery through to discharge, discharge is an interesting one. The more you manage to help colleagues in these hospitals reduce neonatal mortality, the more you're gonna see babies going home with challenging developmental conditions. And if we don't start to pay attention to that, there is a moral a apart from a practical question about what it is that we're aiming to achieve. Again, this is something which is for discussion rather than for solution right now. But you know, these are things that we find out as we, as we go along. Uh Rwanda, we started working in three hospitals in, in 2015 and 16. Uh At the largest point in our program, we were covering about half of the government hospitals in the country and a number of primary health centers. Why do I mention this? It, it is not to boast although I quite like uh boasting. Um it is because at some point earlier on, somebody talked about enabling clinicians in low income country contexts to talk to each other, to learn from each other. And what you get from working in multiple sites in, in a network way is is exactly that effect. But clinicians can start because on the whole, I think clinicians working in low income settings are often pretty lonely. They go to work in their hospital, they go home. It's very hard indeed. And they don't get a chance to talk to people in other places who are actually seeing many of the same things that they are. So getting people together in this way, I think is a very efficient way of accelerating and expanding what it is possible to learn, not from the outside, but from the, from the inside. And then over time from 2015 through to 2022 the green line is neonatal mortality across the hospitals that we were working in. The blue line is comparative hospitals where we were not delivering this program. Uh Again, I think there is a sort of superficial argument that says, well, something good has happened on the whole. I think it probably has, I don't think the college is uniquely responsible for that. I think the college played a small part in, in what's happened because we see secular decline in neonatal mortality anyway. And we know that in these other hospitals, there have been different kinds of interventions going on at the same time. So we can't really disentangle a pure effect. What we can say however is that there has been some positive result. And what I quite like about 2021 is it shows a bump in our data uh which I would expect to have seen uh relating to COVID that makes me feel slightly more reassured about the nature of the data. But the other thing about these data don't forget is that they are probably one of the most powerful motivating factors for political decision making in countries who want to work. When you present these kinds of data to the Ministry of Health officials, they start to feel better about continuing to endorse this kind of intervention approach and not showing data, I think shows bad faith with local colleagues who have every right to ask us to show uh whether what we're doing is effective or, or not. I'm absolutely, I have no idea about the time, but I'm just gonna keep going for a little while and if that's OK. So, so then the challenge is uh based on what we think is some moderated amount of success in the Rwanda program. This is a stack of, of, of uh mortalities. Uh And what we were saying overall is a reduction. This is a population level uh measured by the way, not a facility based level which accounts for some of the difference in numbers. But what we're seeing down here is Macerated Stir which has not really changed over the entire period. One of the things that makes us think is, uh there are quite a lot of things going on in the primary level which are not actually working particularly well specifically around intrapartum uh observation and that um process of referring mothers either identifying high risk pregnancies early enough. So you can refer them in utero or understanding what's going on during delivery and getting them out the door to the secondary level, um in a reasonably efficient fa fashion. Now, a lot of that, you know, you have talked about referral in global health is one of the big issues I think um, the problem is, and the reason people don't talk about it, the reason people refer to it and then move swiftly on is because there's not a huge amount you can do with referral. You can, you can try and improve the observation of the action around the, the assembling side. You can try and do the same on the receiving side. But in the middle, you've got roads and vehicles and foster fuel and who's gonna be driving and who's gonna be taking care of the mother and the baby and all those kinds of things over which we have limited amount of control. Notwithstanding that referral is clearly one of the big issues that, that that needs to be, that needs to be addressed. And I think is pointed to in the experience of our program. The other thing to say, and this brings me back to my earlier point is that, is that quite a lot of our work is, is here in the district hospital because we're a royal college, we have a sort of instinct to move towards guidelines and so on. Um my sense is that guidelines have a limited amount of um value unless they are actually deliverable on the ground. And so one of the key things there is to work out how you can take guidelines from AAA shelf in the capital city and have them available for clinicians at the front line elsewhere. Um We need to understand more about primary health care and care seeking both coming into primary health care and then moving on from the the secondary level. But there are two aspects of this also which I think in an integrated approach to how system strengthening needs to be addressed. What is workforce and it was it was referred to earlier on. But again, there is very limited talk amongst the international donor community about workforce. Why? Because they don't like to pay for it because workforce is a cost that goes on forever. And that doesn't suit down the timelines incidentally. Does anybody know when the word sustainability became a common language in international development? Just ask me. All right. Well, I'll tell you that uh around 1987 around 1987 during what was called the last decade for International Aid, the World Bank started to use the term sustainability in its funding models. Its primary use was with the World Bank and with the international donor community, not with those people working in the hospitals who were being funded. Why? Because sustainability in these hospitals is a very complicated matter. Sustainability from a donor point of view is how quickly can we get out? And this is one of the reasons why workforce financing or some kind of supportive workforce is significantly absent from health system strengthening, both in terms of generalized recruitment and in terms of investment in the educational process. And in terms critically of making sure that nurses, midwives and doctors who come out of their undergraduate training are not just unceremoniously dropped into a hospital with no further supervision at all. Because that basically wastes a third to a half of their capability if you're not structuring an ongoing process through which they can learn and get better. And most hospitals that I've worked in, in low income countries struggle to put that in place because they are resource cool. It is nonetheless something we need to think about because if we don't think about that and we keep on saying we can get better here. We we end up looking a bit and in saying to be to be entirely. But then on the other side, there's what happens to families and kids going home and this is where all water, this is where what I was talking about earlier, the consequences of improving neonatal survival kick in. So we're seeing quite high rates of cerebral palsy in West India, for example, or at least we're seeing anecdotal reports of quite high levels of cerebral palsy. What we're not seeing is particularly credible data sets demonstrating what's going on again. I think there was a discussion earlier on, if you don't have the data on these kinds of things, they will not be part of the political agenda. And there's a lot of missingness in terms of data around postnatal developmental challenges and subsequent disabilities. Partly because it involves a whole new institutional architecture which a lot of governments and low income countries do not have in place the social welfare side of things where you can follow up in primary and community levels with those families where kids have uh longer term ongoing problems. But again, if we're simply focusing on this and trying to get better outcomes here and not thinking about what that means in terms of longer term social participation, economic participation. If you will, then we are missing a very significant part of what health is supposed to mean uh locally and, and, and globally. Oh, look, I did the little powerpoint and skills thing again and I went to stop on that. So I'm strengthening maternity, one child health systems. Uh There are four things that I wanted to talk about with one overriding condition. And then I just wanted to show you a couple of things if I may be be before I finish. So the first thing is, is, is getting policymakers. And I mean, this in terms of the UK as much as anywhere else in the world, getting policymakers to understand you. Investing in maternal and child health is a foundational investment in long term social and economic welfare and indeed growth. I find it staggering that governments including our own still don't seem to get this. And of all the things that you could do, one of the simplest things would be I'd say simplest uh it's quite challenging. But one of the things that you could very immediately do is think amongst yourselves, how do we improve the force of our messaging back to government about what we are doing for them? Because you get a lot of talk about how the NHS is in crisis and so on and so forth. What you don't get is talk about how much incredible value there is from the insider. We have visiting fellows. This is a side issue. We have visiting fellows who come from different parts of the world every year and they spend a month or two on an observer ship in, in, in one hospital or another. They come from India and Pakistan and Nigeria Nepal and so on and so forth. We debrief with them on the way home and we ask them. So what are the things you've seen? What, what, what is the thing you take home with you every time every year? They say it's the system. They don't say it's, oh, you, you do this v er ventilation, it's fantastic or, or you've got these drugs, none of that. They say it's the system, the underlying system and the fact that we deliver it for free. So we're doing a bit of recording with those visiting fellows and we're gonna send a composite of that recording to uh the Prime Minister. Anyway, I digress. OK. So, so, so there's the broad thing, it is probably the best investment you can do. And it's, it's staggering that it's not being done. But then there are uh things that you need to do I think, which are as it were the sort of a part of global health and health system strengthening. The first is data, you know. So II was in Nigeria earlier this year. 10 minutes. Excellent. I was in Nigeria earlier this year. Um About half of the women who turn up French nasal care disappear from the data. By the time delivery happens, nobody knows what's happening to those women. That absence in the data is is just phenomenally worrying, strengthening basic data, I is key. And on the whole, what we've seen is that people try and strengthen data from the outside through big research programs or through the interaction of tablets and other of A I is again, we were talking about this. Uh the the starting point is to work with local clinicians on how and why data should be important to them because unless they are willing to see why data are important, it remains an external burden which is generally speaking, imposed and not particularly well done. That's a real challenge. That's a real institutional challenge. OK. Workforce, we've talked about uh rational investment and again, this referral question, getting people to the right place at the right time is key. Again, it's one of those areas which I think is referred to but not properly uh understood or acted upon and then that question of integrating clinical and social care. What happens in the follow on after Children have gone home? Fine. It's like I'm not gonna spend too much time. People say, look, there's limited amount of money in the global space for health. So just wind you next in. This is the amount of money in 2000 and uh 22 spent on the US Health system. 4.5 trillion in 2023. That's the amount a total of all money spent by global donors on health anywhere in the world. That's it. So when people say there isn't any money, it's not true. That's the first thing. And secondly, it's clear that you can get an awful lot out of small amounts of money if you use it in the right way. OK. And then my last slide, my last slide is, are we using it in the right way? This is aid to health over the last it was 95 to 2017. I got this from the OECD data set. These three lines are the lines around um large scale mass public health interventions and disease control programs, right? Lots and lots of improvement in spending there. These three lines are health personnel development, health policy and administration and basic health infrastructure. And they have flat line over the entire period that is not the rational recipe for a sustainable health uh system. So I'm gonna leave it there, I think. Yes, that's me. Um Thanks for listening and uh well, that all. OK. Thank you so much for highlighting the work of R CPC H Global. Um I'm going to start with a few questions that came in before the conference itself. One is looking at vaccination and what vaccination uptake is like um as well as engaging with multiple stakeholders in unstable environments, particularly conflict environments. OK, thank you very much. I was in Afghanistan uh two weeks ago on the vaccination program there in the eastern region. Uh uptake is still between 40 50%. If you say that to the government, they get very certain because it's not good news for them. So, so they prefer to use a different kind of denominator and that raises the uptake level I II in, in its appearance to about 80 85%. Much more reassuring uh for the likes of gabby and, and global actors that disparity between what is actually happening and what the data are allowed to say. It is one of the key issues in vaccination. Um The other thing I I'd want to say is that is that uh I've worked with lots of different organizations relating to vaccination. Uh You know, wh up being only two of them um on the whole, they prefer to explain poor vaccine uptake as a result of demand side very. And what I mean by that is that the demand side just doesn't understand that vaccines are good for you and they don't like it or they have religious objections or they have cultural objections. We talked about culture earlier on in all of the research I've done on this when I talk to people in household and communities, their main problem is they've asked questions and they haven't been answered. Right. I have very rarely found people who seem to believe genuinely that they are opposed in some foundational sense to vaccination. There is, there's a political organization around religious objection in Northern Nigeria, for example. And that's absolutely true, but that's a political problem. And it's often based on the fact that those communities on the law are being offered vaccines for month, on month, on month, whilst they are unable to get hold of any other kind of healthcare in the world. So what they're saying that the communication back to the government is if you want us to take the, can you please give us some other health services which we actually have reason to, to value. So I think, I think it is a more complex thing than sometimes you know that that demands like narrative. Um Else, thank you very much. Do you have any questions in the room? You can just go to our house and like to thank you doctor. And I was wondering as the pattern of global health funding comes from, has changed over the last decades away from a centralized evaluation, multiple cats and individually funded funds. How have you seen that impact on health systems and what you can get done change based on that? Thank you very much. So, so the fragmentation of the global health funding landscape has that had an impact on the way when she has been delivered? Yeah, on the whole, I think it has and you can take uh gates on the one side as an example where from a government's point of view, I understand they now have six people on their board where they used to have three excellent real progress there. But they are essentially shifting the dial in a way that wh O cannot, that worries me profoundly not because wh O is brilliant, but because wh O has a mandate and it has some control functions around the, the, the w the World Health Assembly which could moderate what it, what it chooses to do. If you look at wh Os own internal funding, it has gone from 20% concessionary funding from individual donors for their pet projects and 80% what wh O could do itself to the exact reverse. 80% of Wh Os funding currently is determined by what each individual donor wants and it makes it almost impossible for wh O to plan out and act rationally in support of these, these countries. And on the gates side, well, they built an entire emergency operations center for on the Afghan Polio program. Uh from start to finish. And I'm not sure that that has improved the program in and of itself. I am sure that it has concentrated on a lot of political power in one building and that makes life a lot more difficult for the regional a to be lower who need to do their own thing. So the answer is yes and not necessarily in a good way. Thank you. Before we got time for one more question in the room. Does anybody else have any other questions? My name is um I mean, this has to do with what your slide mentioned about. It's easy to introduce an improvement but then integrating it and having it sustained by itself. Um What I would like to know is how we can integrate an improvement. OK? And then the um do that require for a doctor going to and do with the health policy and what that would look like when you do that? Sorry. The second part was, would you need to have a doctor from that context go to uh if if, if you are trying to improve and change, would you then need to get involved in health health policy in that? And how would you like to go about doing that? OK. OK. I get it. Yes. Uh I mean if I just by starting to answer the question, it implies that somehow I know what the answer is and I don't know, I'm not in touch with anybody in the room does. I think everybody's got some, some thoughts about this. Um but it is clearly uh one of the big challenges if you want. For example, if you, if you feel like mother care is an important intervention which improves outcomes for mothers and babies i in, in lower middle income settings, in hospitals, how would you try to embed mother care as a practice in, in, in, in, in, in those facilities? Right. Uh Well, we've tried in a number of places and in some of them, it's gone really well and in other ones, it hasn't gone well at all. One of the things, for example, is, is, is working with the hospital administrator because they're the ones who make decisions about resorts allocation. You need a room for K and C, you need a room with some ch chairs which are, which are reasonably comfortable. It needs to be a reasonable temperature. You need to have some access to drinking water and preferably you have to have some access for the mothers to get food at least once a day. Otherwise they have to go outside the hospital to buy the food, right? And that means a bridging the the amount of time they can, they can devote to care your mother. We have got some of the hospital administrations in Rwanda to, to set up really quite good mother care rooms. So that's the resource allocation part in others. We still struggle. That's the truth of it. And then the other part of it I think is who's gonna manage this process from a, from a starting point of view, who, who's gonna take responsibility for this. One of the things I found is a bit of a challenge with KMC is that it's not viewed as a medical intervention and therefore the community of doctors in the hospital are not so interested in it. That's not always true by any means. But that's kind of a dynamic. And then the nurses are the ones who are expected to, to take a lead on delivering K MT or supporting mothers with KMC. And the question there is in a way and I don't mean to be kind of terribly dull about this, but it's a contractual one, nurses are really busy, they've got a whole bunch of stuff they have to do and you're asking me to do a whole new thing and unless you can give them some time to do it and potentially also some, some, some development of skills and and possibly a reflection of that in their career professionally. I don't think you're gonna get the kind of uptake that you need. So, so again, you're talking about the administrative aspects within the hospital agreeing that they want to define um one nurse's task as including at KMC. And then finally, yes, of course, all of that then takes you back to the central level at which point, you have to make an argument with the Ministry of Health as to why this is important. One of the interesting things about KMC is for a long time, the evidence base was pretty limited. There was a whole slew of meetings and research um a few years ago which generated it might be really convincing uh data and we're able to present those data to, to, to government. So I think, I think that's the other level at which you would need to offer. I'll, I'll stop it. Thank you. Thank you so much, Doctor Taylor. That, that's it. We're going to move now to professor has, is the senior and Global Health Vice president of the Royal College of Obstetricians and Gynecologists. He's a UK based clinical director and a consultant and G, and a subspecialist in maternal medicine based at, at University of Hospital. He's a clinical director of Southwest London and Surrey Harland's Maternal Medicine Network and he oversees complex medical conditions, prepregnancy. Exactly. I think I'll be fine. Are you want to? It's not, it's not necessary to. Thank you. Good afternoon everyone. Thank you very much uh for the committee for inviting me and that's a fantastic program. Uh so well done to you. Um So I've actually been asked to speak on the um role of the oncologist for physicians and gynecologist. Can you hear me um in