Flavia Bustreo knows the World Health Organization all too well. She has served within its ranks for more than a decade and is the only internal candidate among those vying for the position of director-general of the U.N. health aid agency.
Being part of the organization could give her an advantage that predecessors have also enjoyed. Six out of WHO’s eight previous director-generals, including outgoing Director-General Margaret Chan, were already working for WHO when they were elected to the position. Yet as member states demand more reforms within WHO, inside experience may also be a liability. They could see her as the candidate who would maintain the status quo at an institution that requires change for efficiency and relevance in the ever-growing global health landscape.
This perception does not escape the Italian candidate. In a conversation with Devex, Bustreo reiterated how she’s spent far more years working outside the organization than in it, and how she, too, has several areas in which she’d like to “drive change” at WHO.
In this Q&A, Bustreo tells Devex her priority reforms for the organization, her strategy for putting them into practice, as well as what she plans to do differently if elected as the next leader of the U.N. health aid agency. This Q&A has been edited for clarity.
What are your main priorities in running for the position of director-general?
As you said, I am the only internal candidate, but I am a very unique internal candidate in as far as I [have] worked for the World Health Organization since 1994. I have more than 20 years with the organization. But I’ve worked with the organization in positions of progressive responsibility. I started with the regional office in Copenhagen. I worked in the headquarters in Geneva, worked in particular on tuberculosis and antimicrobial resistance in tuberculosis. And then also in country office, I worked in Khartoum, Sudan, where I was their adviser for maternal and child health.
But here is where the unique part comes. I have spent so far more years outside the organization than inside, because since 1999, the organization placed me on a special assignment, of secondment, to the World Bank, where I spent six years working on influencing the investment for health that the bank is making in many different parts of the world in many different countries. In Latin America, for example, at the time of the crisis in Argentina, in Brazil for the Programa Saude de Familia (family health program). After that experience, both WHO and the bank placed me to become one of the key engines of… an alliance that is now called Partnership for Maternal, Newborn, and Child Health, which I helped create. I became the deputy director and the director for another six years.
I am saying that because often people ask me — the reporters, but also the countries that speak with me — they ask, ‘ok, if you are from inside, how can you change things, how can you reform things? Will you be just the same old same and the same things that has happened so far?’ And as you know, there are a lot of things that need to change in the organization.
Whoever wins among six candidates for the director-generalship of the World Health Organization will have a consequential impact on the future of agency and of global public health itself. Candidates are promising leadership and bold change. But any reform will have to contest with a WHO's fraught budget, demanding member states and a stultifying bureaucracy. Devex takes an exclusive look at the stakes behind the vote.
So I like to start from that point, because I want to make quite clear that I see a few areas in which I want to drive change and then I’ll speak briefly about the priority in substance that I see ahead of us.
The first thing where I see the organization needs to drive change is [in] securing the sustainable financing for the organization. You cannot have an effective… organization unless it does secure financing. Because, for example, you cannot answer an Ebola outbreak at a time when you are also seeking funds for doing so — that’s not possible.
The way that we look at changing that is, number one, [by] increasing dramatically, exponentially the number of what we call voluntary contributions. I believe there are now in international health a number of partners and players that are willing to contribute to global health, but they are not currently tapped to work with us in WHO. I’ll give you an example. One of the programs under my leadership that is a human reproduction program, we have a list of contributors that are three pages long, because these programs we have been, sometimes for decades… really looking at which partners can contribute. I envisage to do such an exercise, a very intensive exercise, to scope out what other partners out there can support the different parts of the portfolio of the organization. I’m sure this can be successful, because currently how we do [it] is we go back to the usual, same limited number of donors — that are the member states. And for example, how we do this in the context of this financing dialogue is to group them, share with them the situation and the financing. Instead, we need to have meetings where we write many, many more partners.
I also will want to continue looking at the partners that are financing us to make sure that they can continue to give us some latitude for using the resources, or what we called non-earmarked resources. Because again, when you have a situational crisis, if you have resources that are all very tied, very specified for specific activities, you cannot use them. Even the director-general cannot change those agreements. We need to have some resources that are also not specified.
And of course we’ll continue to rely on the regular contributions, what we called the assessed contributions, that member states provide. And finally, to look at sources of innovative financing. I have quite a lot of experience with innovative financing. I was a member of the innovative financing for health task force. I’ve been the vice chair of Gavi, and I’m quite familiar with the power and the possibility, for example, to do advanced market commitment instruments, to use instruments like IFFIm [International Finance Facility for Immunization] that we have used for immunization. Maybe expanding those instruments for health, and by doing so, identifying resources that primarily benefit the countries, but also indirectly benefit the work of the World Health Organization. I believe the WHO has to work in a much, much more efficient way with other financiers in health, [such as] the World Bank, the Global Fund, Gavi and the new global financing facility in support of Every Woman, Every Child.
This is the first area where I see the need for a significant change and a significant reform in the WHO’s current work.
The second area where I think [it] is very important that we change [is] for the organization to become more effective, transparent, accountable. Also the process of decision-making is so slow, byzantine; it has so many different players that even for people like journalists to report, it’s difficult for you to understand where are they in this process of decision-making.
But most importantly, the organization has to achieve results on the ground. This is where I would like the organization that I lead to be measured and to be [held] accountable for. Are we achieving results on the ground and improving the health of the people or not?
To me, one of the ways to do that, to do these changes we haven’t quite tapped yet, is to have independent evaluation of the work of WHO at regular intervals. I have experienced that in the context of Gavi, in the context of the best programs that I have been associated with. At regular intervals, independent evaluations that are not carried out by your staff, that are not carried out by your partners or players that are funding you. They are carried out by independent people. They can give you a picture: are you going in the right direction or not? And if not, how can you course correct?
This is something I know particularly the countries will not be so sympathetic to, but I think we can introduce it [at] the least for some parts of the work of the organization. The one that I’m especially keen [on] is the aspects of the reform of the work WHO does in humanitarian and health emergency in the context of outbreaks. This is a key aspect of the reform that I will want to drive at very aggressively. I know Devex has quite covered extensively the outbreaks of Ebola and the difficulties that the three countries Guinea, Liberia, Sierra Leone, have experienced, and the tragic consequences of Ebola on the health of the people of those countries. But also you’ve seen how much the weakness in the health system in those countries has been compounded by the weakness and the slowness of the international response, including the response by WHO.
I will want to drive the reform of that response very aggressively, taking full account of the International Health Regulations framework, which we currently have, and addressing and strengthening very much the surveillance. Because currently, we live in a world where health cannot remain a domestic concern for anyone. It cannot be a domestic concern in Italy, it cannot be a domestic concern in the U.S., it cannot be a domestic concern in Liberia, because pathogens and threats can emerge anywhere. What we need is a strong system of surveillance that will detect those pathogen threats, and then we need enforcement of the IHR. What does that mean? It means that when countries find that they have Ebola, or that they have Zika, or they have a new form of flu virus, they have to share [that information] with the WHO and with other countries. Part of the weak response in Ebola was a weak surveillance system that took months before the detection of the Ebola virus and the confirmation by the government that indeed they had a problem.
And then of course there is the aspect of creating a workforce within WHO and those across the three levels of the organization that can really respond in short time in a coordinated manner that can tap on the capacity of the organization, but also the capacity of other partners and players. One thing that I have been quite vocal [about] — one thing that I would have done completely different in the Ebola outbreak if I had been in the leadership of this organization — is I would have worked with MSF [Médecins Sans Frontières].
Before joining the [WHO], I worked with NGOs in situations of conflict and displacement. In fact, I started my career working in the aftermath of the first Gulf War in Iraq. I’ve seen the impact of the first Gulf War on Iraqi children. I worked in the Sarajevo, in Croatia, during the war that led to the disintegration of the former Yugoslavia, and I worked there with NGOs and I know that NGOs, including small ones, they are often the first ones on the ground to know what is happening. I remember we were the first ones to provide services to the Muslim refugees — at that time they were internally displaced — that were coming out of Sarajevo when the war started. So [in] short [this is] to say, I would have worked very differently with MSF and the other NGOs at the beginning of the Ebola outbreak. If you remember, they were expressing their concerns, were trying to attract international attention to the problem. I would’ve listened and would’ve worked with them and said, let’s try to find out what the problem is.
These are the key reforms that I see need addressing, and when I speak with journalists and member states, one thing I do say and I want to say to you as well, is I personally feel that in order to make these changes… you have to know the organization — how it is, how it functions, where are the pitfalls, where is the resistance. Because it’s not that others have not tried to make these changes. You have to be very well equipped in order to effect changes.
These are the priorities for reform; I also have some priorities for areas of work in the organization that are already happening, but I’d like to enhance, for example, expanding universal health coverage, the impact of climate change on health and the health of women, children and adolescents.
What will be your strategy for engaging with donors, as compared to how the current leadership of WHO is doing, in convincing donors contributing voluntarily to the organization to give WHO more flexibility?
I like to show things that I have done, because I have done these already to some extent. And you can look at the data presented in the financing dialogue for the category 3 [in WHO’s program budget], which is the part of the work of the organization under my leadership called health across the life course.
You can see that for that part of work, already this year for the next biennium, we have 85 percent of the financing already in hand. It’s the best financed part of the work of the organization. I have done it for the area of work that I’m responsible.
But how did we do it? Because that’s the key.
1. In order to convince your partners to give you latitude, they have to trust you. They have to believe that you produce results. So the first thing you have to do [is] you have to be very credible and deliver. Once you have the reputation that you deliver, then latitude can come in.
2. You can have agreements that have some specifics, even with the same partners. For example, [with] the Nordic [countries], we have agreements that have some areas of specificities, like for example they say they support our work on sexual and reproductive health. But they do not pin it down to specific activities, to specific deliverables, by a specific time. So you have the resources and the objective you’re trying to achieve, but you don’t pin it down to specific activities, and that gives you the latitude that these [goals] require.
Because of that latitude that we have with some of the Nordic [countries], we were able to use some of those resources in the case of the emergency for Zika. We were able to use some of the resources for example to do the studies that are looking at sexual transmission of the Zika virus. We have an agreement with the Nordic [countries] that this is improving sexual and reproductive health rights of people, and in this year, we felt a significant threat to that reproductive health because of the Zika outbreak. As you’ve seen in all the data that was published we have evidence that the infection [caused] by Zika during pregnancy can lead to microcephaly, and we also have evidences that Zika virus can be transmitted by mosquito bites but also can be transmitted by sexual transmission. So if you have resources at hand that are not so tied, you can still address an outbreak and emergency, because you can use these linkages.
3. The other thing that you have to do is spread the risk. If you have five or six partners only financing the emergency reform, it’s very hard, because they have particular priorities. But if you have 20, or you have 30, or you have 50, and if you have different players of different kinds, then you spread your risks. Number one, the risk when they don’t come through with the resources they promised you. But also, you spread your risk that among that big pool there will be partners and players that are not asking you for very specific activities.
Then of course if you deliver results, you can continue to make the case to many more partners, to say, ‘give us voluntary contributions that are not so specified, that are not so earmarked.’ Over time, we have seen that is possible. You need to continue to insist, and you need to continue to deliver results and also be accountable for what are you doing for those resources.
I think under [current Director-General] Dr. Chan, we have made some progress in making public how much resources are coming to the organization from the different players. The organization hasn’t been as good in showing what it is that it is achieving with those resources. To me that’s really key.
What kinds of innovative financing do you have in mind that you’d like to try at the WHO?
Number 1, I will set up a group of people that will work on innovative financing. You can’t have in your pocket just 1 or 2 [ideas]. You have to experiment. And the experimentation takes a little time. For example, in the case of immunization, we have experimented with IFFIm. Now it’s a quite set-up process and quite set-up instrument. So I want to start with experimenting. For example, can we use these instruments [such as] IFFIm for a broader set of activities than immunization. It might be that this idea was very much suited and the market — players and financier have responded really well for immunization — but they may not be willing to use it for broader [issues].
I have several ideas. IFFIm is one. Another that I’ve been thinking quite a lot [about] is how the organization can increase access to drugs, particularly drugs that are very expensive and are currently not available, especially in low- and middle-income countries. I’m thinking of drugs, for example, for the treatment of noncommunicable diseases and especially cancer. One of the ways that we have experimented for attracting private investments and decreasing prices in the areas of immunization is what we call the advance market commitments, or advanced purchase commitments, where we have a group of partners and group of financiers that sign to purchase in advance a certain number of vaccines. We did this in negotiating with two companies for the price of vaccines against pneumococcal pneumonia, one of the main causes of pneumonia for children under five.
So this is another mechanism to give a signal to the market [about] certainty that we will purchase a certain number of drugs at a given price, and we will facilitate the investment that you make in your research and development to produce those drugs.
But the most important part of my answer is, I don’t believe there is one single innovative financing mechanism, and I will not put all the eggs in one basket. I will attract some talents in the organization that can work with me to experiment with a few of these innovative financing mechanisms to ensure sustainable financing.
You talked about your priorities on transparency and accountability, and you placed a special emphasis on results. What will that look like in practice? For example, the organization is currently active in promoting health system strengthening, but this is an area that’s not easy to measure when compared to something like delivering vaccines to a thousand children.
Reaching and expanding the universal health coverage is one key priority I have, and obviously to do that you have to address the system barriers that affect many countries.
I think the way you have to approach this is you have to give them the successes we’ve had, for example, the treatment for HIV and AIDS. If you go back 15 even 20 years ago, antiretroviral treatment was not available for a young woman infected by HIV, AIDS in Africa. And now, a young woman has the options, number one to be tested, and number two to have access to treatment for herself and if she’s pregnant and delivers her baby, also for newborn.
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So you have to build on those successes. In order to build a system, you [need] progressive realization. You cannot build a health system suddenly that is able to treat all the illness and avail access to services for all people. You have to drive progressively. Number one, to reach everyone.
A lot of our conversation has been around immunization, but even for immunization services, a program that has been in existence for more than 50 years, we still don’t reach — on average around the world — 1 child out of 5. We still have a huge gap in order to leave no one behind.
So to answer your question, how do you show the system is being strengthened: you have to continue using some indicators of coverage of services and you also have to inject into this indicators of, for example, health workers — health workers presence in terms of number, health worker capacity and quality of care they deliver, as well as financing, in terms of what part of the services are covered by the government, how much of those services are paid out of pocket, what proportion of the budget of the government goes for health.
I believe there are ways that you can show the progress in expanding universal health coverage and strengthening the health system. But you have to keep it really simple. Because number one, it is really difficult for a common person to grasp this concept. Number two, if you want to show results on the ground as we discuss them, you have to be very concrete. You have to talk about, for example, the proportion of girls that receive human papillomavirus vaccine, or the proportion of women that are screened for cervical cancer or the proportion of women that are treated for cervical cancer. You have to link it back to what we call the health outcomes. You cannot have this discussion very theoretical, because otherwise you lose people.
Cervical cancer is one typical example where now we have more than 30 countries, because of the investments of Gavi, [that] have started introducing human papillomavirus vaccine. This is one of the first vaccines that we have available against cancer. And we now need to follow through in countries with a true public health approach. The public health approach means primary prevention — we do that through the vaccines. Secondary prevention — we do that through the cervical cancer screening. Unfortunately in many parts of the world, even just the screening is not available. And then the full public health approach means treatment. In parts of the world like my own, treatment for cervical cancer is now something very easy. If you have precancerous lesions, you can have a very easy treatment. If you have cancer, you can be treated with drugs and you have a significant possibility to be cured. But in most parts of the developing world, this is not possible.
The last part of the public health approach is also palliation. I know because I’ve seen it in the years I worked in Italy as a clinician, you always have people that, no matter what you do, they will not survive those illnesses. The system needs to be able to offer them some palliation, and the ability to die in dignity. Not to die suffering excruciating pain and being left alone or even worse, stigmatized, because they were not able to overcome the disease.
That is the way I look at expressing the results on the ground.
You mentioned Gavi and their role in getting the HPV vaccine to more than 30 countries around the world. How do you show these successes to donors and link back to what WHO’s efforts and contributions were?
I believe it is very important for WHO to work with other partners and players. I believe nobody can do things alone in the 21st century.
It’s also very important, as you say, to have attribution of roles, and attribution of what is your contribution to the results.
The way we do it, for example in the case of immunizations and vaccines, is we have a very clear role in the Gavi, the Vaccine Alliance for WHO. The policy that the alliance uses — decisions about introductions of new vaccines — are all determined through WHO’s scientific advisory group of experts. For example in the case of HPV, all the work that WHO did was at the beginning of the process. Number one, do we have an efficacious vaccine? Number two, do we have a cost-effective vaccine? Number three, is now the time for countries in their current health systems to introduce new vaccines that have additional complications? Because these vaccines have to be given to adolescent girls from 9 to 13 years of age, and many countries don’t have an experience of vaccinating young girls. We have a lot of experience vaccinating young children, or vaccinating adults, but that particular age group — adolescents — is difficult to reach.
All policy decisions were done by WHO, and only when those policy decisions were agreed did a financing instrument now called Gavi apply the resources. We normally make it quite clear that this is our work.
The second [job we have is] in the introduction of countries, both WHO and UNICEF — again I have to say as this is a partnership — were very involved. We looked at how these countries should plan the introduction step by step, really the nitty gritty activities.
You have to show your contribution to the activities on the ground, and you also have to show, like in the case of polio, the very, very important contribution the organization gives to monitoring and strengthening the surveillance of these activities, because that is a crucial aspect.
I’m glad you raised the polio eradication example.… Rotary is an incredible partner and has been an incredible partner all along. But without the World Health Organization, the polio eradication would not have existed, because the organization was the convenor of the effort and has a tremendous role particularly on the surveillance of the threats — of where is the polio virus, how we do shape the tactic to continue this battle on eradication, etc.
So in answer to your question on how you claim attribution, you have to document very carefully what you do, and you have to show the results of what you do in the context of the alliance work. I’m not discounting or suggesting that suddenly we should say WHO did all the work on polio eradication and the others are not important. No. You have to show that you are good partners, but you also have to be very clear on what the organization contributed to.
There are two more things I want to express as priority for the organization, which otherwise we may not have time to cover.
One is [something] I’ve included quite high on my program, which is addressing the impact of climate change on health. I see this with quite significant urgency, because we have now a pressing need to understand why climate change causes changes to, for example, the disease spread in new areas, how it impacts the disease vectors. For example, we have now evidence we can have transmission of malaria in parts of Africa at an altitude where before we never had a transmission. And it is because of the rise in temperature in those areas.
Climate change affects health through not just the transmission of diseases but also because it’s linked to food security in many parts of the world because of the drought and floods. Because of all the changes linked to climate change, we have food insecurity, we don’t have access to safe water and also clean air.
To me, this is an important priority, and the organization has started doing work on this. But we really need to enhance it aggressively moving forward. It is a high visibility issue where countries have committed through the Paris agreement to action, and I see it as very important for WHO and for the health sector to be examples of how addressing the impact of climate change can produce a win-win.
If you have a health sector that becomes carbon neutral and contributes to decreased emissions of CO2, you can also have strong benefits for health, for example through the reduction of air pollution that causes more than 7 million deaths every year. This is a key priority that is very new, has not been very big in the portfolio of the WHO, and I will want to respond to it significantly.
With so many new players now working in public health, some have raised questions about whether WHO is relevant in the same way that it was before. How would you address these concerns?
Maybe it’s not just relevance. There is a new architecture, there are a lot of new actors in global health. And to me the organization has to reaffirm its role of coordinating those actors and being part of the discussions that happen.
We have to be very, very aggressive and position of the organization in those alliances. I have experience of having done that, for example the new Global Financing Facility in support of Every Woman and Every Child. We have been very engaged in the content: how is it going to be set up? What would be the rules of the games? How does it work in countries? That is one way you assert your relevance, because any new initiative that comes, you are part of it and you shape it because of the traditional historical knowledge the organization has but also the legitimacy.
On the question of relevance, you have to ask the corollary question, which is, ‘what is the legitimacy of some of the new actors?’ One of the things that became very, very clear about the Ebola outbreak was there were not significant other actors that had the legitimacy of WHO. Even [German] Chancellor Angela Merkel, when she came to the WHO to speak at the peak of the Ebola outbreak crisis, said this organization has the legitimacy to coordinate our efforts and others do not have [it].
But what I detect is not just relevance but also what I call the deficit of enthusiasm.
There are a lot of people who are questioning the values, who are not excited and enthusiastic about this organization. To me, one of the ways to address that is to involve young people. [For example,] in the partnership for maternal, newborn and child health, under the leadership of Ms. Graca Machel, we created what we called a new youth constituency. We have an enormous group of young people who are so enthusiastic about working in global health. They are very vocal actors; they are very candid and very enthusiastic. The way I see it also in addressing relevance is to address this gap in enthusiasm and bring in partners and players like young people, like parliamentarians, for example — they are always very interested in what is their role in domestic matters to enhance health, but also internationally.
My strategy will be to increase the enthusiasm of the organization, because I know by doing that, I’d also be able to enhance the relevance. Because when you have around you a group of friends and players who are very committed to the work of the organization, then you become very relevant.
WHO currently has a wide remit — it has been asked to do a lot, but not necessarily been given the resources. Are there areas of WHO’s work that you would amend or even eliminate?
I think this is very, very important question, because there is always a demand for more work, but where are the resources to address that?
The way to address those remarks is, number one, working with the governing bodies of the organization to make sure that they don’t place additional demands. There has to be a way to contain the demands for the work of the organization. That’s number one.
The second thing is looking at the reach portfolio that we have of the organization’s work — there are aspects of the work that can be carried out by others. For example, in the past the organization used to do a lot of work on training health workers for their capacity to provide services. I myself did a lot of training, for example, for health workers for what kinds of services and how the services should be provided to women and children.
But currently I think there is a lot of capacity, for example, to use south-south cooperation to do that: to engage very valuable trainers and very valuable health workers and professionals from India, China, Russia, and to have all of them engage in strengthening capacity of countries with less capacity. That can free up the work of the secretariat team of the organization to maybe have a different role, maybe to coordinate that. But they’ll need much less resources to do that. I will look at what are the things that currently the organization [does that] can be streamlined, where the organization can not have a primary role.
Number two, I will also look at [whether there] are aspects of the work of the organization that maybe are more interested regionally and therefore the regions can take a bigger lead.
But the north star in all of these to me would be independent evaluation, because if you have independent evaluation at regular intervals, you can present your partners and member states and say look, this is where the organization is performing well, and this is where we have comparative advantage and capacity and we should strengthen that, and this is where the organization has not been able to perform well and therefore maybe we should think about not working in this area anymore or having a different role in these areas.
I will not be deciding this by myself because I like an area, I don’t like an area. It would be totally inappropriate. It will have to be driven by the accountability that is provided by independent evaluation and discussions with the countries and the partners.
You mentioned doing some things differently during the Ebola crisis, for example working with MSF. How would this have played out? Is it something that could inform your work with MSF and other partners if you become director-general?
There is one thing I want to tell you that you might not know about me, but if you will work with me you’ll find out. If you want to ask people who have worked with me, they will tell you: in my work, there have been critics. The first thing I do about the critics is I reach out to them. I really believe that very often people criticize you because they care. They don’t criticize you because they’re mean or because they want to take you down. They care. They care about the work that you do.
So number one, my philosophy always is, whenever I receive criticism, I reach out to the critical voices and I engage them in a dialogue. I want to understand their reasons, and I want to understand why they are saying what they’re saying. In the context of MSF, I would have engaged the leadership of MSF and the coalition of MSF in trying to understand — not to dismiss their reasons — but to understand, what evidence do you have? What data do you have? What are you showing, what are you seeing in countries? When you do that, you turn the table around, because you are listening and then you’re saying, so how do we solve this together?
I worked in Khartoum in Sudan with the WHO at the time when we did not have the meningococcal vaccine. There is a so-called meningitis belt, which is in sub-Saharan African countries of the Sahel. There are a large number of countries there that used to have periodic epidemics of meningitis, and when I was working in Sudan, we had major massive outbreaks of meningitis across the meningitis belt, including in Sudan.
During that time, there were just two of us international staff in the Khartoum office. And my most valuable players were the MSF colleagues, because they helped us. Immediately they joined the office, they sent experts to work with us and government to assess the extent of the epidemic, where are the cases, how is the transmission, etc.
I’m just saying that organizations like MSF in countries are extremely valuable, because the organization [WHO] in many countries doesn’t have a large number of staff. You can strengthen that, but I don’t think we’ll suddenly have hundreds of people working in the WHO offices. So you need to work with partners and players, and particularly in the outbreak and emergency response, partners like MSF are very, very valuable.
So [during Ebola,] I would have reached out, engaged in a dialogue, asked how do we work together to address this? What can you do and what can you do with us?
Unfortunately the response we had was to dismiss. To dismiss, “no they are wrong, no this is not true, or we’re not hearing the same and the government are not saying the same.” And very often, organizations like MSF do have a pulse on the situation on the ground.