funds to deal with the direct disease, but also to build the type of structure in the country. president clinton, you said one thing that really got my attention, and i want you to expand on this, about not tolerating corruption. because the countries in which you both have been actively involved, there is a lot of corruption. but evidently you have been successful in getting the funds for health to the people and not being diverted to fund the greed of certain corrupt officials. is there a lesson that you can help us with? as we tailor foreign assistance, we look at ways of changing our foreign aid focus to make sure there is transparency, to make sure there is oversight and accountability, so we don't find that the international assistance is going to fund corrupt regimes. >> i would be interested -- i

don't think i have ever had a conversation with bill about this. i'm not in the position i was in when i was president. when i was president, the question is, is this government corrupt? and to what extent? now i just don't want the health care programs to be corrupt. they can't take the money and the medicine i bring in there. this is a good way in to building good governance and honest governance in countries, because you can argue that corruption in health care programs kills people. the only country i ever pulled out of, and i don't want to cause any embarrassment here, insisted on paying $880 for my then $140 a year aids drugs. the leader of the country who i had a good relationship with said why do you care?

i said because this is a little world, and three days from now, they will know it in africa, and if somebody in africa does what you did, then six people will die for every life i save. if you have so much money, hire somebody else to run your aids program. i am just saying that because i do believe that the health care issue is a good way in. but also, if you do it -- you see, i can do this, and you may or may not want the state department to do this, a.d., or the new global health initiative. i can go into a place, and it is enough for me if we run the health program honestly. i try to build capacity. i don't buy this medicine. i am very careful with the words i use. most of this money we have impact on, we never touch. this goes directly to the government, and they buy the number. we just cut the deal. i don't want them to need me. i want them to build capacity.

there is one country of the 70 where i buy the medicine because the president is a friend of mine. he called me and said look, there was a lot of corruption in the previous government, and i have to get rid of a lot of people, and i can't start with the health ministry. can you buy the medicines for a year or two? they recognize that we had to operate honestly. my advice to you is decide will you only go into places that are 100% clean? or will it be enough that nobody messes with american money and that there is integrity in the health system. i would argue to you there is less corruption where you improve capacity. it is worth a lot to save lives and build capacity. people are so proud in doing that that you will perhaps create a different culture in these countries if you do it.

if you want to say this, you have to be prepared to walk away. i only had to do it one time. did i it and hated it, but touf do it. >> you have to have accountability. mr. gates, have you confronted corruption in the countries you are operating in? >> well, fortunately, things like vaccines or bed nets are not that attractive for the political elite to stockpile. so if you contract the -- if you can track the grant to purchase the commodity and the commodity delivered, you can make sure the money is not being diverted. it gets more difficult when you get into personnel systems and even health systems, to make sure the work is actually being done, that the jobs aren't just given to the politically favored as opposed to the people who have the skill sets. that is not always executed

very well. we see programs like in ethiopia where that is being done well. we see places like india, where the results are mixed. the north, which has the greatest need, tends to have the most difficult challenges. the answer in many locations is to organize women's groups and to make sure they have the expectation that their kids will be vaccinated, that they will goat a bed net. and in a lot of locations, their activism has been key to make sure that nothing is lost between the money being given and the services being delivered. in the case of vaccination, and people claiming they are doing it when they are not, it is easy to go in and do surveillance. there is also a disease, measles, that shows up in people who claim to have high rates and don't. >> thank you. >> senator casey. >> mr. president, you are

grateful four tft here, and your presence, mr. gates, as well. as we were reviewing these issues, i was thinking about the impact you have on the world on a whole host of issues relying to global health. in one sense it is incalculable , and in another sense very measurable. two among many numbers jumped out at me. reducing malnutrition among more than 42 million children, and provided access to safe drinking water to three million people in asia. those are important results. it is important to focus on results. there are so many ways to document the problem, so many ways to specify the nature and the gravity of the threat to human life, but the american people more and more look to us and look to non-governmental

entities for results. i wanted to focus on two areas. one is on maternal and child deaths, and two, on food scute. let me cite two memos from the -- two numbers from the staff memos. subsharon -- sub-saharan africa-asia, accounted for 94% of alma ternl deaths in 2005. chilling numbers. the question i have is two-fold. one is we know this year the the's 2011 budget provides $9.6

billion for global health activities. if we had another billion or two to spend, and you could only spend it hypothetically on maternal and child health, how would you spend those "in-game extra" dollars, how should we spend it if we could only spend it in these areas? and secondly, just a brief list of what works. sometimes i think we have these discussions or debates, and we don't itemize or list what we know works or what we can invest in and get results? >> well, i think if i had another billion dollars to spend, if you take ethiopia for for example, i don't know if you were here when i said this. when we started in ethiopia, there were only 700 clipics in the country. that is before the united states program got underway. and we helped them develop a

plan to go to 3,500 clinics. so i would go in and try to make sure that every pregnant mother could be checked, could be part of some community health work or network and eventually get to a clinic before a baby is born and we could find out what the deal is. i would make sure that we had adequate nutrition. i would make sure that in the high prevalence areas we tested for h.i.v. status and gave the mother-to-child transmission drugs. i would then fund those things which reduce infant mortality. you talk about all these kids that died being in africa, but the mortality rate is very grief us for babies born with h.i.v.-aids, even though we save a lot of them. it is horrible. 80% of the people who die from

waterborne diseases are under 5. they are almost all in poor countries. that is what i would do. i would spend the money on that. >> i mentioned the drop in childhood deaths from 20 million to 9 million. we can think of the row mange work as the deaths between 30 days of age and 5 years, where it is really going to be vaccines that are going to carry the weight. we have a new vaccine for part of the diarrhea burden and the pneumonia ya burden. hopefully we will have both of those and a malaria vaccine. if you can cut those diseases, then you can cut the 30-day to 5-year piece by well over half. that still leaves a large number under 30 days. if you get the mother starting prenatal, making sure she has

the right vitamins, perhaps vaccines, make sure she has the clean birth kid, some antibiotics, make sure she has been given the right advice about keeping the baby warm, breast feeding, vaccination. that integrated approach can safe over half of the children that die during that first 30-day period. that is a big new focus not only of the d.h.i. plan but of work that we are doing. exactly how you go about that is not well understood. the vaccine piece, we need to put more into research. the model is pretty clear there. this first 30 days piece, there is a lot we know, but there is more that we need to know particularly because creating the demand by the mothers within their culture and social practices, that they will want these services. many places you go where your

child has chills, take them down to the clinic. they say that is where children die. why would i take my child down there. there are going to be things that are going to be tailored to each local area. >> senator casey, if i could just say something. bill just said something, and i know everybody on the committee understands this, but it is important. partly because of the way programs get funded in the countries provideing aid, and partly because of assistance provided in poor countries, the most important thing maybe about this d.h.i. proposal is providing a coherent health system as sort of a one-stop place in developing countries. i mean it is crazy they don't have enough money to do anything -- this program is dealing with aids, and this program is dealing with

maternal and child health, and this program is dealing with malaria, and there are literally places in the poorest places where you may have to walk three, or four or five places to get everything your family needs. this is what the global initiative, among other things, will correct, and give the rest of us marching orders and a framework so we can all be more effective and make the money you have appropriated go further. i think it is important that everybody understands. it is hard to imagine that it exists, but it does and is one of the most important reasons to pass the g.h.i. >> i hate to use the word fault, but is that the consequences of what we are doing or not doing or the consequences of what the individual countries are doing or not doing? >> probably a little bit of

both. but i think that a lot of people in developed countries are providing aid with good intentions. we started the pep-for program, the global fund on h.t.b. and malaria. you can't start a program against h.t.b., maternal and child health and immunizing against tropical diseases and other things -- what we said earlier is the united states and other dopors need to be in the business of making this a user-friendly system and also helping to build the capacity of the countries in which we work. hopefully one day they won't need us any more, or anybody else. but i think what happens is -- if you deal with these things problem after problem, you have

unintended consequences. if you put the problem solvers into an environment where there is no system, like we take for granted for health care. >> so what you are saying, when these things are done, they should focus at the outset on system and process as much as delivery? >> absolutely. the problem debate in rich countries about health care policy and education policy. they are about how do you change the system you have what is the right way to do it? what is the wrong way to do it? you know you have to keep improving. in poor countries, they are about compass iity. they have no systems. there is no connection between what you do and consequence you get. this is nobel work, and you can see the u.s. government doing more of it. the bill gates foundation and i

have been involved in all this. i fell into this, too. i'm just as guilty as the next person. we did aids drugs, and cut the price, and then something on malaria. then we realized that the impact of all this is being drastically truncated because there were no systems for people to show up and get maternal and child health, offense. >> thank you. >> thank you. i want to add my thanks to everyone else's on the panel for both of you for being here today and for all of the work that you have ton. thank you both very much. for the last year, along with senator snow, i've served on the smart global health commission of csis, and we are getting ready to produce a report that will come out next week. it reinforces so much of what both of you have said today.

many of your friends and colleagues have served on that commission with me. mr. chairman, i would like to ask unanimous consent if we can submit in the report an advance copy of the csis report on smart global health policy. one of the things talked about in that report is exactly what you both said about building a system that can deliver results . as we look at how to structure that kind of a system that i think is important not just in terms of delivering results, but in producing a base that we can go back to people, whether it is funders, governments or the american people and say look, this works. we have the accountability and the data to show that.

can you talk a little bit more about that, about how we structure those systems that are accountable for people? >> well, in some ways, compared to all the money you spend, had is the most accountability money, more than money you spend on medicare, the defense budget and education. this money, you can say we have spent this many dollars and saved this many lives, at levels it is pretty stunning that those resources weren't there in the past. the piece that isn't in the 150 budget, the research pieces that are over in the other thing, those are a little tougher because we can't see how quickly you will get an aids vaccine. we know it is important work and eventually one will come, but that is a long quest, probably more than a decade.

but when it comes to giving money to global funds, or the global alliance for vaccines, there is a very direct measurement of how many kids' lives were saved with these new vaccines or how people more people were able to go on treatment. i wish all of government had such a clear -- if you spent money, then you will absolutely get these results. there aren't many things you coming from 20 million deaths down to nine million deaths. it was less than half a percent that allowed that to take place. >> i completely agree with that , but i am a bleeding heart cheapskate, and we need more

money for medicine for reasons we have already outlined. i do think this is an appropriate time, senator, for you to reexamine the transaction cost, the compliance cost and the overhead cost, to see if you can squeeze any more money out of the money that congress appropriates and get it down to the countries needing it for buying medicine. one of the things in the report on the global health initiative that the administration has issued. there was a mention in passing of cooperation with n.g.o.'s, but one of the things that we really haven't worked through is exactly what should the nature of the government's cooperation with n.g.o.'s should be. i described my relationship

with the bush administration, and all that. but i am in a different position. i can't get u.s. government money. although we have made our health initiative free-standing to the event that is his necessary sometimes. you need to think about how you do these things faster-cheaper-better and whether we have the highest percentage of dollars being spent in the countries you intend them to go to possible. in my opinion, senator, there may be some things you can do to better that. all these things are scoreable. you can keep score. you know what you got for the money you spent, and you know what you would have gotten if you had spent it on other things. but that doesn't mean you shouldn't keep trying to get more blood out of the turnip. we have desperate needs. the more we build these systems, the more people will show up. you don't want to have five years from now riots in

countries because they can only give medicine to 45% of the people who need it to stay alive, and the other 55% you didn't see before you built the system for it to touch them. >> well, that leads me to raise another issue that has been a sensitive and controversial issue, but i think it is important as we are talking about how do we best invest the dollars. as we all know, family planning remains a controversial issue in this body and the country. mr. gates, you mentioned in your written testimony that voluntary family planning is a proven and cost effective way to save lives. according to the csis report, for every $100 million invested in family planning, 4,000 maternal lives are saved, 70 thousand infant deaths are averted, and 25,000 abortions

are averted. how can we move this debate beyond being controversial to another way to accomplish what we need to, to deliver health care around the world? >> mr. president, you have a deadline as i understand? >> no. i can stay until ten so 12. >> i see doug dancing behind you going what? that is all right. thank you, mr. president. >> well, i think the best way to change people's minds would be to have them go to the countries and see what is being discussed when we talk about family planning in these countries. talk to the mothers who want access to the tools. the tools can improve. a lot of women use injections. right now that is a needle, so

you have to go to a health worker. there is a new advance that is subdue cane umass where they could get it at the pharmacy or administer it themselves. the implants have been way to expensive. there is a new generation of those coming out that are substantialally less expensive. what family planning means is bringing down by choice the rate of population growth and having more birth spacing. that is very dramatic in terms of improving maternal health. if you wait two years between children, it cuts more than half the chance that there will be a maternal complication. and so it is very effective. in these very poor places, the high population growth caused

because you don't have access to these tools when you want them, that builds in huge problems in the future. it is great that the u.s. is looking into these investments and that that receives somewhat of an increase in the g.h.i. budget. it is an important area of spending and as place your organization prioritizes as well. >> i don't know whether this will work or not, but i think the foreign relations committee should start with members and staff members going to see some of these places, because i think -- look, when a pro life person hears the word family planning, they think, you know, abortion, they think license,

and all these things. if you could see these things in operation, they come across as clearly pro family and profoundly pro life. these important women, they are just trying to manage their lives, and if they space out the births, like bill said, they can do a better job as mothers. they can still work and earn income for the family. it changes everything for them. so i personally think that your best bet is for people, whether they are viscerally for this or against it, to actually see it, see how it works in real people's lives. i think that would change things. and i don't think you should give up on this. who would have thought that jesse helms would have supported the global debt

relief in 2000? i think it is very important to keep working at it. believe me, most people who talk about family planning have never seen it in operation on the ground, on-site. >> thank you. >> senator brasso. >> thank you for being here. i appreciate the work that both of you continue to do for the benefit of all humanity. mr. president, i agree with you completely when you talk about vaccines. they are cheap and they work. and i agree with recruiting, training and keeping health care providers, whether physicians or nurse practitioners. and i agree that you must be invited in, and they must have a plan and have measurable results. i saw in my 25 years as an orthopedic surgeon how important though things are, early detection and prevention,

and the one-stop shopping where people can go whether for malaria or aids, whatever the disease. what i hear from my colleagues, who has had a chance to visit a number of locations, is that the patients and people want to go to the gates facility much more than the local state-run or government-run facility, because they have to walk to the clinics. but apparently you have come up with a better way with transportation in sending a van 230 miles around. it is not just the health care, but all of these other ancillary things we can do to help improve the system. i look forward to having a chance to visit the facilities as well. mr. gates, if you could talk about that, how the gates foundation has said up criteria for when you decided to get involved and holding people accountable for a continuation of support, because you actually do want to make sure that the value is there for the

dollars invested and that the best results can be obtained. >> well, the gates foundation gives money to the global fund because we think it is a great organization. i think we have given $650 million to them at this point. they work with the countries. they are quite low overhead in terms of how they do it. in terms of setting up clinics, there is a difference between high aids prevalence countries and low aids prevalence countries. a lot bit of the mistake was taking the model from high aids prevalence countries. where people are trained in special ways makes sense. we are talking about countries in south africa. if you