With failures occurring at all levels, the recent Ebola outbreak in West Africa exposed significant weaknesses in the global health system and culminated in a tragic humanitarian disaster. At the national level in affected countries, there was significant delay in acknowledging the magnitude of the outbreak. And after the outbreak was recognized, the international response was slow and uncoordinated. Mechanisms for the establishment of public–private partnerships were lacking. For example, the development of lifesaving medical products was reactive, rather than proactive. An easily mobilized reserve of funds to support the response was not available. Critical financial and human resources were slow to arrive or never arrived at all. Countries were reluctant to acknowledge the severity of the outbreak and obstructed early notification. Surveillance and information systems were not in place or failed to provide early warning.
All three affected countries lacked an adequately trained workforce, infrastructure, supplies, and the necessary medications to respond to the outbreak. Moreover, these three countries had never experienced an Ebola outbreak before making this an unexpected and more challenging situation to respond to. All this contributed to widespread fear and questioning of the ability and willingness of governments and humanitarian agencies to respond effectively, and, in many places, people were reluctant to seek health services (WHO, 2015a). These and many other factors contributed to an outbreak with devastating health, economic, and social impacts.
Past outbreaks of other diseases, including H1N1 influenza, severe acute respiratory syndrome (SARS), and human immunodeficiency virus (HIV), have also had significant economic and social impacts. These outbreaks, like Ebola, exposed weaknesses in national health systems and the global public health response, but did not galvanize the degree of reform required. This most recent Ebola outbreak triggered several initiatives calling for change:
- The World Economic Forum (WEF), in collaboration with the Boston Consulting Group, published Managing the Risk and Impact of Future Epidemics: Options for Public–Private Collaboration in June 2015. This report explored the role of public–private partnership when responding to epidemics, using lessons learned from the Ebola response (WEF, 2015).
- In January 2015, the World Health Organization (WHO) Executive Board’s special session on Ebola adopted Resolution EBSS.R1, establishing an independent, expert panel to evaluate WHO’s response to the Ebola crisis. The panel was established in March 2015 and released its report in July 2015 (WHO, 2015b).
- The Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine set up the Independent Panel on the Global Response to Ebola to create actionable change through assessment of the global response. This report was released on November 23, 2015 (Moon et al., 2015).
- The United Nations (UN) High-Level Panel on Global Response to Health Crises was convened by UN Secretary-General Ban Ki-moon. This panel will make recommendations on the basis of a wide range of consultations across sectors and in affected communities, and will submit its final report to the Secretary-General in early 2016 (UN Secretary-General, 2015).
- Finally, to address deficiencies in the financing of outbreak response, the World Bank Group has launched an initiative to create a Pandemic Emergency Financing Facility (PEF). The PEF is expected to provide financial resources for global health emergencies to allow for the rapid deployment of equipment, medications, and human resources (World Bank, 2015).
TABLE 1-1 Other Relevant Initiatives
|Global Health Security Agenda||U.S. government in partnership with other nations, international organizations, and public and private stakeholders||Created to prevent, detect, and rapidly respond to threats of disease before they become epidemics.||Affirmed September 2014 Second Ministerial Meeting September 2015|
|Managing the Risk and Impact of Future Epidemics: Options for Public–Private Collaboration||World Economic Forum and Boston Consulting Group||Explored public–private partnerships when responding to epidemics using lessons learned from the Ebola response.||Report published June 2015|
|Independent Panel to Assess WHO’s Response to Ebola Outbreak||World Health Organization (WHO)||Convened by the WHO Director-General to evaluate WHO’s response to the Ebola crisis.||Report published July 2015|
|Independent Panel on the Global Response to Ebola||Harvard Global Health Institute and London School of Hygiene & Tropical Medicine||Determined necessary reforms to the global system for outbreak prevention and response, considering evidence from the Ebola epidemic.||Report published November 2015|
|UN High-Level Panel on Global Response to Health Crises||United Nations||Convened by the UN Secretary-General to make recommendations for strengthening national and international systems to prevent and manage future health crises.||Report to Secretary-General January 2016|
|Pandemic Emergency Financing Facility||World Bank Group||Proposed to hold financial resources for global health emergencies to allow for rapid deployment of equipment, medications, and human resources.||Will be presented in May 2016 at G7 meeting|
For additional information on these relevant initiatives, see Table 1-1.
The National Academy of Medicine (NAM), internationally known for rigorous procedures to ensure independence and the ability to convene experts with broad multi-disciplinary reach, was encouraged by multiple stakeholders to assemble global experts to develop a plan for future preparedness and response to global infectious disease threats. After two planning meetings, the NAM became Secretariat for the Global Health Risk Framework for the Future (GHRF) initiative—an international, independent, evidence-based, authoritative, multi-stakeholder expert commission process to generate a comprehensive report with recommendations for improving governance and finance in matters of global health security pertinent to infectious disease outbreaks of international concern. The initiative received support from the Paul G. Allen Family Foundation, the Ford Foundation, The Bill & Melinda Gates Foundation, Mr.
Ming Wai Lau, the Gordon and Betty Moore Foundation, The Rockefeller Foundation, the U.S. Agency for International Development, and the Wellcome Trust.
The GHRF Commission was tasked with conducting a study and preparing a report to recommend an effective global architecture for recognizing and mitigating the threat of epidemic infectious diseases. While our report focuses on the preparedness and response to these infectious disease threats, we acknowledge that the implementation of our recommendations will also help address other global health concerns such as the increasing appearance and spread of antimicrobial resistance (AMR). For instance, the strengthening of surveillance systems and laboratory capacity that will help us be better prepared to respond to infectious disease outbreaks, will also facilitate early identification and actions to prevent further transmission of a resistant strain.
The complete statement of task is provided in Box 1-1. Four Institute of Medicine (IOM) workshops were held on the following topic domains to provide input for the Commission’s final report:
- Governance for global health,
- Financing response to pandemic threats,
- Resilient health systems, and
- Research and development of medical products.
The Commission was asked to consider the evidence supplied by these four workshops, as well as literature already published on lessons learned from the recent Ebola outbreak and other outbreaks of global impact. It is important to note that the charge of this Commission was not to provide a comprehensive analysis of the lessons learned drawn from the recent Ebola outbreak, but to draw on previous work to develop an understanding of common lessons learned from different previous in-
fectious disease outbreaks to inform the Commission’s recommendations. We strived to identify those lessons learned that could help us develop a framework that can effectively address future known or unknown infectious disease threats. Summaries of four IOM workshops developed to gather evidence for this study (as described later in this chapter) were published in January 2016 (see nam.edu/GHRF for more information). These summaries compile the experiences related to issues of health systems, governance, finance, and research and development as shared by participants including those from the recent Ebola outbreak.
The statement of task required that the Commission deliberate and evaluate options in these four topic domains to strengthen global, regional, national, and local systems to better prepare, detect, and respond to epidemic infectious diseases. The Commission was charged with offering conclusions and actionable recommendations to guide policy makers, international funders, civil society organizations, and the private sector.
The initiative comprises an International Oversight Group (IOG), an independent Commission, and four IOM workshops that provided evidence to the Commission (see Figure 1-1).
International Oversight Group
The IOG, a body of leaders representing various stakeholders with relevant expertise and global representation, was formed to ensure the independence and objectivity of the Commission, and to protect integrity and maintain public confidence in the process. The IOG steered the Commission throughout the process, including by creating the charge to the Commission, approving the slate of Commissioners, guiding report review, and as-
sisting in the dissemination process. The IOG was tasked to:
- Determine the scope of the study: In preparation for this study, NAM staff worked with sponsors and technical advisors to develop a formal statement of task, which defined and bounded the scope of the study and the balance of perspectives needed on the Commission. The IOG reviewed the proposed statement of task to ensure that the task reflected the current global need for such a framework and made refinements as needed.
- Approve the Commission slate: The NAM received and reviewed more than 150 nominations for commissioners. Commissioners were proposed for service based on their expertise, geographic representation, and availability to perform the task. The IOG assessed whether the expertise required was present in the slate proposed and evaluated the overall composition of the Commission in terms of different experiences and perspectives. The IOG also defined what constituted a conflict of interest and if its presence should prevent an individual from serving on the Commission. In addition, the IOG determined whether a conflict of interest was unavoidable and how it should be handled. A primary goal of this process was to ensure that Commissioners’ points of view were balanced so that the Commission could carry out its charge objectively and credibly.
- Approve the Commission process for meetings, information gathering, deliberations, and report drafting: The IOG approved the Commission’s approach as outlined in the following section.
- Provide guidelines for the report review process: As a final check on the quality and objectivity of the study, the IOG determined the characteristics of the external review process for the final report and provided suggestions for specific processes. The review process was structured to ensure that the report addressed its approved study charge and did not go beyond it, that the findings were supported by the scientific evidence and arguments presented, that the exposition and organization were effective, and that the report was impartial and objective. The IOG did not review the report draft or provide comments on the report conclusions or recommendations.
- Assist with the development of a dissemination strategy: Dissemination of the final report is a key component for the success of this initiative. Therefore, the IOG assisted with identifying key decision makers and audiences, developing a dissemination strategy, and participating, if feasible, in its implementation.
The Commission is made up of 17 experts drawn from different nations and representing a wide range of expertise, including governance; finance; disease control; surveillance; workforce mobilization; humanitarian and pandemic response; health systems; public–private partnerships; social science; and research, development, acquisition, and distribution. The Commissioners were screened for conflicts of interest in order to ensure their independence.
The Commission held three meetings and one public session (see Appendix A) during the course of its work in 2015. At these meetings, Commissioners took time to understand their charge, considered evidence, and formed recommendations.
The Commission’s deliberations were based in large part on the evidence gathered and discussed at four IOM workshops in late 2015 (see Appendix B for workshop agendas):
- August 5–7: A Workshop on Resilient and Sustainable Health Systems to Respond to Global Infectious Disease Outbreaks, Accra, Ghana
- August 19–21: A Workshop on Research and Development of Medical Products, Hong Kong, China
- August 27–28: A Workshop on Pandemic Financing, Washington, DC, United States of America
- September 1–2: Governance for Global Health—A Workshop, London, United Kingdom
To fulfill its statement of task in regard to financing response to pandemic threats, the Commission worked with two consultants. They provided technical expertise in pandemic financing and modeling the business case for investing in preparedness for global health events. The consultants communicated with Commissioners via
conference calls, and Commission deliberations determined how the consultants’ analysis would be incorporated into the final recommendations.
Other Sources of Information
Two consultation sessions were organized to complement workshop discussions and ensure that government, private-sector, civil society, and academia perspectives were captured:
- September 25, 2015: Session with members of the U.S. federal government, Washington, DC
- October 9, 2015: Webinar session with international and national representatives from multilateral organizations, academia, nonprofit, and private sector
The Commission also conducted consultations with WHO Director-General Margaret Chan on November 20, 2015, U.S. Centers for Disease Control and Prevention Director Thomas Frieden on October 21, 2015, and World Bank Group President Jim Yong Kim on November 12, 2015, to gather updated information about their respective organizations’ current efforts on global health preparedness and response.
In addition to the workshops, Commission meetings, and consultations, the Commission conducted a literature review on infectious diseases, pandemics and pandemic risk, governance for health, finance, health systems, research and development, aid effectiveness, and existing global health frameworks, among other topics.
The Commission also coordinated with many of the other global initiatives tasked with developing recommendations for improving the response to future global public health threats (see Table 1-1). It is important to note that, while some GHRF Commissioners contributed to other initiatives, this study preserved its high degree of independence and the integrity of its processes as outlined in this chapter.
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. Reviewers were approved by the IOG. The purpose of this independent review was to provide candid and critical comments that will assist the Commission in making its report as sound as possible and to ensure that the report meets standards for objectivity, evidence, and responsiveness to its charge. Reviewers were asked to consider whether in their judgment the evidence and arguments presented were sound and the report was fully responsive to the charge, not whether they concurred with the findings. The Commissioners were expected to consider all review comments and to provide written responses, which were evaluated by the review coordinator. The report was not released to the sponsors or the public, nor was it disclosed until after the review process was satisfactorily completed and all Commissioners approved the revised draft. Furthermore, once the review process was successfully completed, no changes (other than minor editorial emendations) were made to the approved text. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
The remainder of this report is organized as follows:
- Chapter 2 builds the case for a greater investment in pandemic preparedness.
- Chapter 3 discusses the importance of national public health systems, including the need for objective and transparent assessment of national core capacities, for building and sustaining strong health systems, and for engaging and communicating with communities.
- Chapter 4 reviews the need to strengthen international capabilities for outbreak preparedness, alert, and response, including the role and responsibilities of WHO, coordination among global actors, a revamp of processes and protocols, and mobilization of global financial resources.
- Chapter 5 presents the importance of accelerating medical products research and development to counter the threat of infectious diseases and outlines a global strategy to facilitate this—including a plan to develop a Pandemic Product Development Committee, invest in a comprehensive portfolio of medical products, conduct research according to high scientific standards, and secure overarching global agreements.
- Chapter 6 reviews the steps necessary for building a framework for global health security and overcoming the associated financial challenges.
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