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Introduction¹

From its onset in December 2013 to its slow disappearance in late 2015, the West African Ebola epidemic has revealed deep and pervasive fault lines in the existing mechanisms to address emerging infectious disease threats to global public health—faults that have been previously identified, warned against, and largely met with inaction through various World Health Organization (WHO) review panels and by infectious disease experts. Nearly 6 months after Médecins Sans Frontières brought the Ebola epidemic in West Africa to the world’s attention in March 2014, WHO declared the outbreak to be a public health emergency of international concern (PHEIC), triggering powers under the 2005 International Health Regulations (IHR).² By November 2015, the epidemic had resulted in more than 28,000 cases and 11,000 deaths.³

Beyond the near-term challenge of ending ongoing Ebola transmission, this epidemic has again demonstrated the inadequacy of the international framework for managing global public health communicable disease events.

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¹ The planning committee’s role was limited to planning the workshop. This workshop summary has been prepared by the rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine and should not be construed as reflecting any group consensus.

² The IHR are explained in detail in Chapter 3.

³ Total suspected, probable, and confirmed cases and deaths from the 2014 West Africa Ebola outbreak as of November 1, 2015. See more at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html (accessed November 30, 2015).

Governance structures—intra- and interinstitutional and across sectors—did not perform as intended, and insufficient communication across vertical and horizontal response structures added to the misunderstanding of severity. The Ebola outbreak grew to catastrophic proportions in Guinea, Liberia, and Sierra Leone and began to threaten nations far beyond West Africa.

Over the past 40 years, globally significant outbreaks of HIV/AIDS, H1N1 influenza, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and other infections have illuminated many of the same deficiencies in global health governance. Lacking the political will to create and implement a robust global public health framework, many thousands have lost their lives, and billions of dollars have been incurred in economic damage. Once again, multiple expert panels have been assembled at international levels to assess what went wrong in this latest public health crisis, and to recommend actions related to governance of global health that can be taken at the national, regional, and international levels to prevent another outbreak from emerging and negatively impacting so many countries and populations.

THE GLOBAL HEALTH RISK FRAMEWORK INITIATIVE

Since the 2014 Ebola outbreak many public- and private-sector leaders have seen a need for improved management of global public health emergencies. The effects of the Ebola epidemic go well beyond the three hardest-hit countries and beyond the health sector. Education, child protection, commerce, transportation, and human rights have all suffered. The consequences and lethality of Ebola have increased interest in coordinated global response to infectious threats, many of which could disrupt global health and commerce far more than the recent outbreak.

With encouragement and input from the World Bank; WHO; and the governments of the United Kingdom, the United States, and West African countries; and support from various international and national organizations (Ford, Gates, Moore, Paul G. Allen Family, and Rockefeller Foundations; Dr. Ming Wai Lau; the U.S. Agency for International Development; and the Wellcome Trust), the U.S. National Academy of Medicine agreed to manage an international, independent, evidence-based, authoritative, multistakeholder expert Commission⁴ on improving international management and response to outbreaks. As part of this effort, the Institute of Medicine (IOM) convened four workshops in the summer of 2015 to inform the Commission report. These workshops examined questions of governance for global health, pandemic financing, resilient health systems, and research and development of medical products. Each workshop gath-

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⁴ For more information on the Commission, see http://nam.edu/initiatives/global-health-risk-framework (accessed October 20, 2015).

ered diverse perspectives on a range of policies, operations, and options for collaboration to improve the global health system. A published summary from each of the workshops has been independently written and reviewed, and their release will be coordinated.⁵

MEETING OBJECTIVES

Building on more than a decade of workshops on such topics as SARS, H1N1 influenza, and the emergence of MERS, the Academies’ Forum on Microbial Threats coordinated the Governance for Global Health Workshop, which was held on September 1-2, 2015, at the Wellcome Trust in London, United Kingdom. The workshop was designed to explore global, national, and local capabilities, to include those required by the International Health Regulations (2005); to facilitate the collective action of the governmental, intergovernmental, corporate, and nonprofit sectors as they contribute to preparedness and response; to describe options to strengthen global, regional, national, and local systems to better prepare, detect, and respond to epidemic diseases; and to study interrelations between sectors.

“We are here to consider the key elements of good governance for global health, to characterize the needs, gaps, and barriers in our current approaches, to consider alternative models of global health governance, to examine indicators and metrics of an effective, accountable, anticipatory and resilient system,” David Relman of Stanford University told workshop participants. This effort, he continued, supports the Global Health Risk Framework Commission’s goal of building actionable recommendations that lead to improved global health governance: a high-stakes result on which the health and welfare of the world’s population depend.

This document is a summary of the presentations and discussions that took place at the workshop and is not meant to be a comprehensive overview of how best to achieve ideal governance for global health security issues. Achieving compliance with the core capacities of the IHR and improving the complex systems within which WHO, the United Nations, member states, and nonstate actors work together is a multifaceted and challenging ambition. Due to limitations of attendance and the rapid timing of this workshop, this summary captures suggestions and ideas from individual speakers and participants on how to accomplish these goals, but they may not be complete or all-encompassing. For workshop objectives, see Box 1-1.⁶

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⁵ Summaries from the other three workshops can be found at http://iom.nationalacademies.org/reports/2016/GHRF-Finance; http://iom.nationalacademies.org/reports/2016/GHRF-Health-Systems; http://iom.nationalacademies.org/reports/2016/GHRF-Research-and-Development.

⁶A full statement of task for the workshop can be found in Appendix C.

ORGANIZATION OF THE REPORT

This workshop report summarizes the discussions that took place in London, including perspectives around the need for global health risk governance, as well as potential models for consideration. Chapter 2 discusses the definitions of governance and the field of players involved, and Chapter 3 highlights lessons illuminated from past outbreaks—with several still waiting to be implemented. Chapters 4 and 5 cover the challenges for fragile states and challenges in designing strong governance for global health. Chapters 6 and 7 take a more in-depth look into suggested elements of a governance framework and potential models for comparison that could be employed by WHO and other stakeholders. Finally, Chapter 8 shares some closing thoughts on the four models presented at the workshop, paying particular attention to decision making, measurement, and accountability.