While reinforcing the first line of defense at the country level is the foundation of the global health risk framework, strengthening international capabilities for outbreak preparedness, alert, and response is a second vital component. Improving and maintaining international capabilities is essential because infectious disease outbreaks quickly transcend national borders. Infectious disease outbreaks also require response strategies that extend beyond health—encompassing areas such as transportation, commerce, trade, finance, law, and communication.
Swift and strong coordination among a diverse set of global actors is required across a broad range of outbreak preparedness and response actions, including management of logistics and deployment of international medical teams (see Annex 4-1 for other essential functions needed for outbreak preparedness and response at the international level).
Global action is an imperative because pandemic prevention and response are global public goods. Outbreak identification, prevention, and control efforts by one country benefit not only that country, but all countries (Jonas, 2013). Weaknesses in one country endanger not only the local population, but all of humanity. Global health security is the opposite of a zero-sum game—benefits obtained by one country do not reduce benefits available to others, but actually increase them. However, as with all public goods, global health security suffers from free-rider incentives and coordination challenges (Frenk and Moon, 2013; Jonas, 2013). Therefore, strong international norms and collaboration are essential.
To ensure that critical functions for pandemic preparedness and response are performed well at the international level, the Commission recommends major changes to current global and regional arrangements. We believe that the World Health Organization (WHO) should play the leading role in coordinating pandemic preparedness and response, consistent with its constitutional mandate. Yet WHO needs to play this role much more effectively. To achieve this, WHO should:
- recognize the significance of its role by creating a robust operational entity and contingency fund that can respond adequately to potential pandemics;
- improve its ability to coordinate and cooperate with others in the global health landscape, including other United Nations (UN) agencies, regional networks, and non-state actors; and
- redesign key protocols that would encourage early alerts and reporting and enable swift international response.
The Commission also believes that the multilateral finance agencies, such as the World Bank and International Monetary Fund (IMF), must play a leading role in mobilizing global financial resources in response to potential pandemics.
With a constitutional mandate to be the global leader in disease surveillance, outbreak investigation, and response, WHO has the authority and obligation to play a significant role in delivering a range of essential functions (see Annexes 4-1 and 4-2 for more detail), including pro-
viding technical assistance and aid in emergencies.1 In addition to its constitutional mandate, WHO’s role is enshrined in the major treaty governing global health security, the International Health Regulations (IHR). The World Health Assembly (WHA) has also adopted numerous resolutions supporting WHO’s mandate.2
However, the Ebola crisis exposed many weaknesses in WHO’s leadership and capabilities. Most notably, WHO did not help mobilize personnel, materials, and finances rapidly or at scale, despite clear evidence that the outbreak had overwhelmed the capacities of both states and nongovernmental organizations (NGOs) (MSF, 2015). There were communication and coordination breakdowns among WHO, other agencies, and actors in the affected countries. There was duplication between humanitarian and outbreak clusters, causing confusion and inefficiencies.
To fulfill its constitutional mandate and regain the trust of governments and the public, WHO must make significant changes, strengthening its organizational and operational capabilities to lead and support outbreak preparedness and response while ensuring sound governance principles (Gostin, 2014).
WHO Center for Health Emergency Preparedness and Response
The Commission considered four potential models of governance for global health security that were presented at a September 2015 Institute of Medicine workshop on governance for global health.3 Details on these models are provided in Annex 4-3 and in the published report of the workshop, Global Health Risk Frameworks: Governance for Global Health: Workshop Summary (NASEM, 2016). To summarize briefly:
- Model A proposes that WHO strengthen execution of its responsibilities for outbreak preparedness and response through improvements to existing structures.
- Model B proposes the creation of a WHO center for humanitarian and outbreak management, overseen by a dedicated board, to give WHO more robust operational capabilities for outbreak preparedness and response.
- Model C proposes that WHO execute a strategic and operational role in a health emergency under the formal mechanisms of the UN system.
- Model D proposes that the UN create a new interagency entity for global health risks that would encompass capabilities not only from WHO, but also from other UN agencies, such as the Food and Agriculture Organization (FAO) and the United Nations Children’s Fund (UNICEF).
Assessing the Models
Model D is clearly sub-optimal. Creating an additional UN entity would dilute WHO’s credibility and form overlaps and duplication in partnerships, ties with health ministries, and legal authorities. Moreover, without established relationships and access to WHO’s other capabilities, the new entity would find it difficult to manage the essential link between improving preparedness and managing outbreak response.
The reforms suggested for Model A are necessary, but not sufficient. More significant changes are required to ensure that WHO can fulfill its mandate effectively.
The Commission proposes an approach based mainly on Model B, with elements of Model C. Under this approach, WHO would have a new center with clear responsibility, resources, and capabilities to take the lead on outbreak preparedness and response, while taking advantage of the UN system’s assets and being held accountable by a separate board chaired by the WHO Director-General (DG). Establishing this center, with a dedicated board, would strengthen WHO by providing a much stronger focal point for outbreak preparedness and response, and by establishing more apolitical governance and accountability arrangements for this vital component of WHO’s role.
In fact, several other initiatives, including WHO’s Ebola Interim Assessment Panel, have proposed models along broadly similar lines, incorporating elements of Models B and C (see Annex 4-4 for a snapshot of the proposals). Moreover, the DG has already begun to implement changes based on these proposals and input from member states (see Table 4-1). Specifically, the DG has already taken steps to create a program that would
2 Just to name a few, the World Health Assembly (WHA) resolution 58.1 on health action in relation to crises and disasters; WHA 59.22 on emergency preparedness and response; and WHA 65.2 on WHO’s response and role as the health cluster lead in meeting the growing demands of health in humanitarian emergencies.
3 This workshop was held in London on September 1–2, 2015. For more information, see http://www.nap.edu/catalog/21854/global-health-risk-framework-governance-for-global-health-workshop-summary (accessed March 24, 2016).
TABLE 4-1 Reform of WHO’s Work in Outbreaks and Emergencies
|A Unified WHO Program for Outbreaks and Emergencies||Fully integrates the functions and units across country, regional, and headquarter levels that work on outbreaks, on emergencies, and on risk analysis and assessment under the IHR. Includes a platform to provide operational and logistics support for preparedness and response operations in communities and countries.|
|Global Health Emergency Workforce||Promptly and efficiently deploys workforces (comprising national responders, international responders from networks and partnerships, responders from UN agencies, and WHO standing and surge capacity) for service in countries that request or accept such assistance, for adequate periods of time, and with adequate resources.|
|WHO Contingency Fund for Emergencies||Provides initial funding that is flexible, sustainable, complementary to existing and planned mechanisms, accountable, adequate, available, accessible, and designed to prevent a given event from escalating into to an emergency.|
|R&D Blueprint for Infectious Diseases with Epidemic Potentials||Maps existing knowledge and good practices, identifies gaps, and establishes a roadmap for R&D preparedness.|
|Reinforcing the IHR||Supports development of priority IHR core capacities as an integral part of resilient health systems to enable rapid detection and effective response to disease outbreaks and other hazards. Ensures improved functioning and effectiveness of the IHR through the creation and report of the Review Committee to examine the role of the IHR in the Ebola outbreak and response.|
NOTE: IHR = International Health Regulations; R&D = research and development; UN = United Nations; WHO = World Health Organization.
SOURCE: Adapted from WHO, 2015c.
effectively integrate functions and units—across country, regional, and headquarter levels—that work on infectious disease outbreaks, on emergencies, and on risk analysis and assessment under the IHR.4 Although the Commission welcomes such steps, we propose some modifications and areas of emphasis.
Program Versus Center
The Commission agrees that a new operational entity should be established within WHO to bring together and strengthen its capabilities to manage and coordinate preparedness and response. However, we believe it should be developed and described as a “center,” rather than a “program,” as we understand it is currently envisioned. WHO has numerous important programs that aim to advance global health. Yet we believe it is important to distinguish WHO’s entity for outbreaks and health emergencies. This should be firmly established as a permanent part of the WHO system and given sufficient and sustainable funding to fulfill WHO’s leadership mandate.
Specifically, we propose that WHO should establish a Center for Health Emergency Preparedness and Response (CHEPR). The CHEPR would operate in a nimble, scientific, and apolitical manner, coordinating operational information and resources for strategic management of infectious disease outbreaks and other public health events and emergencies, including the growing threat of antimicrobial resistance (AMR). Similar to what has been proposed by other post-Ebola reform initiatives, the CHEPR would have robust capabilities to manage surveillance for outbreaks and events, risk assessment, planning and execution of response, assessment of IHR functions and compliance, coordination with partners, risk communication, quality assurance, and monitoring (Moon et al., 2015; WHO, 2015a,g).
Moreover, the CHEPR should coordinate the global health emergency workforce (WHO, 2015d). To facilitate this, it should strengthen the Global Outbreak Alert and Response Network (GOARN), which pools human and technical resources from existing institutions and networks to support international outbreak identification, confirmation, and response. GOARN has faced challenges in scaling up responses to outbreaks, given
4 Personal communication, Director-General Margaret Chan, World Health Organization, November 20, 2015.
limited numbers of staff and the challenges of finding personnel who are ready to deploy rapidly and possess relevant experience (WHO, 2015f). The CHEPR should strengthen and expand GOARN, integrating national, regional, and global capabilities to reduce the current over-reliance on a limited group of partners. It should also ensure that members are trained and engaged in different stages and tasks of preparedness and response, including sharing information on alerts, risk assessments, integrated data management, logistics and communications, and field-based administrative procedures and protocols.
Although the CHEPR should operate within the WHO Secretariat and be led by an Executive Director, it should be overseen by a Technical Governing Board (TGB), as detailed below.
Executive Director and Staff
An Executive Director at the level of Deputy DG should lead the CHEPR, and the post should be filled through an external, open recruitment. The CHEPR staff should have a variety of skills in areas such as management, health security, public health systems, epidemiologic surveillance, medical anthropology, risk communication, clinical medicine, health information technologies, logistics, security, and technology. In addition, staff should have excellent leadership competencies and a thorough understanding of diverse cultures, laws, and governance.
Technical Governing Board
The Executive Director should report to a merit-based and multidisciplinary TGB. The TGB should be chaired by the DG, who should nominate members strictly on the basis of their technical expertise—not on member state representations. Members should come from various countries, regions, and sectors, including civil society organizations (CSOs), academia, and the private sector. Additionally, the TGB should include representatives from the UN and possibly the World Bank to enable multisectoral support and coordination of WHO’s efforts. Some of the members of the TGB should head technical committees linked to the board. For example, a member of the TGB should head the panel tasked to oversee the assessment of national core capacities (see Chapter 3 for more on this panel). Similarly, a member of the TGB should head a committee tasked to prioritize diseases and research and development (R&D) needs (see Chapter 5 for more on the Pandemic Product Development Committee). Members of these committees should be appointed by the DG based on their expertise and should be mostly external to WHO. TGB responsibilities should include the following:
- Recruit, appoint, support, and evaluate the CHEPR Executive Director.
- Ensure the CHEPR’s fiscal integrity and preserve and protect its assets, including allocating, prioritizing, and safeguarding funds such as WHO’s Contingency Fund for Emergencies (CFE) (discussed later in this chapter).
- Ensure that the CHEPR’s policies and processes are current, properly implemented, well prioritized, and of high quality.
- Regularly review the latest information on threats that have the potential to become a Public Health Emergency of International Concern (PHEIC), drawing from the high-priority “watch list” of outbreaks (discussed later in this chapter).
- Make recommendations to the DG, including when to call an emergency committee and declare a PHEIC (although the DG should still retain the legal power to make final decisions on both of these matters).
- Oversee implementation of mechanisms to reinforce and monitor country reporting and compliance with the IHR.
- Oversee implementation and deployment of the global emergency workforce.
- Hold the CHEPR accountable by setting clear standards and objectives, monitoring and evaluating performance, and issuing periodic reports, which should be made public.
- Report to the WHO Executive Board and the WHA on the progress of the CHEPR.5
Integration Across All WHO Levels
WHO regional and country offices play important roles in promoting and coordinating efforts to counter infectious disease outbreaks. However, some WHO regional offices have faced challenges in working effectively with countries, with WHO headquarters, and with each other
5 Additionally, as stated in Recommendation A.3, an independent review of the entire global health framework, including an assessment of the performance of the TGB, should be conducted in 2017 and every 3 years thereafter.
(WHO, 2013). The discordant relationships were evident in the recent Ebola crisis, hindering swift and effective outbreak response (Gostin and Friedman, 2015). Additionally, recent surveys found that most WHO staff, especially at the headquarters level, view coordination and cooperation among headquarters and regional offices as not adequate (PWC, 2013; WHO, 2012). Although the WHO constitution gives WHO’s governing bodies and the DG formal authority over the regional bodies, in practice, they have limited influence on the conduct or staffing of regional offices because authority rests with the regional directors, who are elected by regional member states (Clift, 2014). The election process makes the regional directors accountable first to their region’s health ministers, rather than to headquarters, thereby impeding WHO’s ability to act as a unified organization (Fineberg, 2014; Gostin and Friedman, 2015). The resulting lack of coordination is a particular hindrance when WHO needs to act decisively and swiftly in response to an outbreak.
To prepare and respond to outbreaks effectively, WHO must be able to speak and act coherently and consistently across all levels. Therefore, all relevant departments at WHO headquarters should be moved to the CHEPR, and equivalent structures and operating systems should be established at the regional level. Specifically, existing functions for health security and emergencies in regional offices should be merged (if this has not already been done) and vertically integrated under the CHEPR command-and-control structure. Further, the regional directors should only have “dotted-line” geographic oversight of these regional functions. Comparable systems should be set up at the national level as well, with linkages to the regional level, along similar lines as the regional and headquarters centers (but adapted as suitable for the country context).
Recommendation C.1: By the end of 2016, the World Health Organization should create a Center for Health Emergency Preparedness and Response—integrating action at headquarters, regional, and country office levels—to lead the global effort toward outbreak preparedness and response. This center should be governed by an independent Technical Governing Board.
Financing WHO’s Leadership Role in Pandemic Preparedness and Response
Providing Funding Support for the CHEPR
The CHEPR must be supported with adequate resources to effectively perform its role in preparing for and responding to a potential PHEIC. Within the constraints of this exercise, we have had neither the access to information nor the time to construct detailed estimates of the additional resources required for the CHEPR or the extent to which WHO might be able to fund this incremental expenditure from savings elsewhere. Moreover, as noted earlier in the chapter, the CHEPR’s role would extend beyond infectious disease threats to cover other health emergencies, such as the growing threat of AMR or biological terrorism. The resource requirements arising from this broader role are beyond the scope of this report.
For WHO to perform successfully its leadership role in countering the threat of infectious diseases, it needs stable and sufficient funding for the CHEPR. The Commission believes that the incremental funds needed should be acquired through an increase in WHO core contributions earmarked for this purpose, rather than through voluntary contributions, because preparedness and response to health emergencies must be supported as an ongoing core function of WHO. Analysis of WHO’s budget allocation for responding to public health emergencies shows that funding has been responsive and erratic in the past, following a “boom-bust” pattern (Hoffman, in press).
The Commission is aware that there has been considerable debate about the adequacy of WHO’s overall core funding from assessed contributions, because it has remained flat in nominal terms for more than two decades (WHO, 2011). However, we have not attempted to address this broader issue, because it involves aspects of WHO’s mandate and performance that are beyond this Commission’s charge. For the purposes of estimating an aggregate level of funding required by the Commission’s proposals, we have assumed that an increase in the core contributions from countries of 5 percent, or roughly $50 million6 over 2016–2017, would suffice to cover the incremental operational costs involved in the formation of the CHEPR. This corresponds to the increase recommended by WHO’s Ebola Interim
6 All monetary figures in U.S. dollars.
Recommendation C.2: In May 2016, the World Health Assembly should agree to an appropriate increase in the World Health Organization member states’ core contributions to provide sustainable financing for the Center for Health Emergency Preparedness and Response.
Providing Contingency Funding for Emergency Response
In addition to financing the CHEPR, there is a need for contingency funding to enable WHO to respond more rapidly to potential pandemics and to fill a critical gap from the onset of an emergency until resources from other financing mechanisms begin to flow, such as from the UN’s Central Emergency Response Fund (CERF) and donors.
The WHA has already approved the creation of a $100 million contingency fund, the WHO CFE, which aims to support WHO’s initial response to outbreaks and emergencies (WHO, 2015h). Financing for this mechanism appears somewhat uncertain. The proposed approach is via voluntary contributions, yet thus far pledges from member states amount to less than one-third of the sum required. Deployment of the CFE would be triggered at the DG’s discretion based on a justified, technically valid, budgeted request from the WHO incident manager, with initial funds to be made available with only minimal bureaucratic stipulations. Funding will be available for up to 3 months for deployment of emergency health personnel, coordination of medical response and transportation of personnel and supplies, information technology and analytical support of emergency response efforts, and creation and operation of field offices (WHO, 2015h). To ensure accountability and transparency, the CFE is subject to WHO’s Financial Regulations and Financial Rules, and all income and expenditures from the fund will be reported annually to the WHA and donors and posted on the WHO website.
The Commission supports this proposal, as it offers the DG flexibility to move rapidly to respond to an outbreak, either after having declared a PHEIC or even before. Accountability for disbursements could be achieved through oversight by the TGB. Ultimately, the CFE’s disbursement would also be constrained by the need to maintain good faith with member states, ensuring their continued willingness to fund replenishment. The proposed quantum of $100 million appears reasonable as a first source of funding that would complement other sources of emergency funding such as the World Bank’s proposed Pandemic Emergency Financing Facility (PEF) (discussed later in this chapter), the UN’s CERF, and contingency funds held by other agencies (e.g., UNICEF, the Global Fund), at a regional level, or by individual member states.
Because the purpose of the CFE is to provide immediate and flexible financial resources in the event of an emergency, the CFE needs to be fully funded in advance or have immediate access to funds. There are at least four possible routes to achieving this:
- Via an increment to the biennial assessed contributions: The problem with this route is that with, say, a further 5 percent increment to assessed contributions, it would take 2 years to fund the mechanism. Thereafter, the fund would either be in surplus or deficit depending on whether or not any disbursements were made. It does not seem optimal to fund a contingency vehicle via a regular payment mechanism.
- Via voluntary contributions: This is the route currently envisioned by WHO. The challenge here is securing sufficient contributions.
- Via committed one-off initial contributions, assessed pro rata with the core assessed contributions: In this route, each member state would make a contribution to the fund in line with and in addition to its share of core assessed contributions. This could either be on the basis of actual cash contributions or via binding contingent commitments to fund the CFE. In the event of the DG’s triggering the contingency fund, WHO could raise money from banks immediately against these binding commitments. Following deployment of all or part of the contingency fund, the DG would then ask for a replenishment round on the same basis.
- Via an insurance scheme: The potential role for pandemic insurance is discussed in more detail below with respect to the World Bank’s PEF. However, insurance is unlikely to be optimal for the CFE, given that the purpose of this fund is to have immediate discretionary funding flexibility. It would seem dif-
ficult and certainly costly to structure an insurance arrangement that pays out on a sufficiently early discretionary trigger, particularly when the DG controls the trigger and receives the payout.
Given the potential for deficits (or surpluses) under Option 1, the potential shortfall and inequity under Option 2, and the costs and technical difficulties attending Option 4, the Commission recommends Option 3 as the optimal approach to funding the WHO CFE.
Recommendation C.3: By the end of 2016, the World Health Organization should create and fund a sustainable contingency fund of $100 million to support rapid deployment of emergency response capabilities through one-off contributions or commitments proportional to assessed contributions from member states.
To carry out its leadership responsibilities more effectively, WHO needs to improve its ability to coordinate across all three levels of the organization and with others in the global health landscape. These global actors include the UN, formal and informal regional networks, local and international CSOs, the private sector, and the media. Rather than waiting for the next outbreak, the WHO should proactively build relationships with these actors to identify their roles and responsibilities and establish ways of working together to leverage their strengths and improve coordination.
Coordination mechanisms among WHO and other UN agencies should be strengthened to enhance outbreak preparedness and control. The Ebola outbreak showed that agencies within the UN Health Cluster failed to communicate and coordinate well with each other—or with other international, governmental, and nongovernmental actors—resulting in delayed, misinformed, or inadequate response efforts. For example, the UN Mission for Ebola Emergency Response (UNMEER) was created even though other regional and sub-regional entities, such as the Sub-Regional Ebola Operations and Coordination Center, and existing resources could have been leveraged to provide more timely and effective response efforts.7 To avoid such duplicative and costly efforts, responsibilities and accountabilities need to be made clear through common protocols and regular communication and strengthened through practice exercises.
Under the global health risk framework, the default or routine operations of the CHEPR should remain within WHO and be overseen by the TGB. However, when a crisis escalates to the extent that it poses a high-level global health threat or evolves into a much broader humanitarian crisis, WHO should then play its role within a broader effort led by the UN Secretary General (UNSG). Because UN representatives would serve on the TGB, the UN would always be informed about possible threats that could require broader UN system support. In the case of such a high-level threat, the TGB (chaired by the DG) should report to the UN-led effort to ensure an integrated, holistic response. The UN would provide leadership and coordinate the efforts of the international community to support affected countries via the Inter-Agency Standing Committee (IASC), chaired by the Emergency Relief Coordinator. This would help ensure the appropriate level of political and financial commitment and facilitate intensified responses from other UN agencies.
Recommendation C.4: By the end of 2016, the United Nations (UN) and the World Health Organization should establish clear mechanisms for coordination and escalation in health crises, including those that become or are part of broader humanitarian crises requiring mobilization of the entire UN system.
Regional Networks (Formal and Informal)
As we argued in Chapter 3, national capacities for disease surveillance and outbreak investigation and control are the first line of defense against potential pandemics.
7 “UNMEER was established on 19 September 2014 after resolutions from the United Nations General Assembly and the United Nations Security Council on the Ebola virus disease outbreak in West Africa. […] The mission functioned by bypassing existing mechanisms, rather than by engaging the United Nations cluster system. While the approach was adapted in countries where the United Nations Resident Representative was engaged with the system, there were other instances where the wider United Nations system was not effectively involved and pillars of work were not coordinated with the cluster structure. A number of stakeholders at country level also reported that the mission was unwieldy, and said that it took two critical months to establish itself at the height of the epidemic when parts of the existing cluster system could have been used instead” (WHO, 2015g).
However, despite the IHR commitments, many countries fall short. Regional and sub-regional networks, both formal and informal, can play a key role in addressing and mitigating these deficiencies by spreading best practices, providing economies of scale, and improving cross-border cooperation. For example, regional manufacturing and stockpiling of medical products and equipment may be more efficient and practical than national efforts. In a similar vein, health worker shortages in one country might be alleviated by neighboring countries. As discussed in Chapter 3, regional professional registries, laboratory networks, mutual assistance agreements, and preparedness exercises against potential scenarios could complement global approaches, with the advantages of proximity, cultural competency, and epidemiological familiarity.
While WHO’s regional offices have contributed significantly to outbreak preparedness and control, some neighboring countries find it difficult to work together under WHO structures because they belong to different WHO regions (WHO, 2013). Examples include Thailand and the Mekong Basin countries, Myanmar and China, and Indonesia and Malaysia/Singapore. However, in the past two decades, countries have formed less formal regional or sub-regional networks, such as Southern African Centre for Infectious Disease Surveillance in Africa, the Mekong Basin Disease Surveillance, the Association of Southeast Asian Nations in Southeast Asia, and the Middle East Consortium on Infectious Disease Surveillance in the Middle East. These networks have built trust and developed formal and informal communication flows that enable rapid and continuous communication when outbreaks occur and joint investigations when outbreaks affect border areas. These sub-regional networks should be interwoven with WHO regional offices, which would enable a strong and prompt collaborative response to pandemics.
Recommendation C.5: By the end of 2017, the World Health Organization should work with existing formal and informal regional and sub-regional networks to strengthen linkages and coordination, and thus enhance mutual support and trust, sharing of information and laboratory resources, and joint outbreak investigations among neighboring countries.
Many non-state actors can and do play significant roles in protecting global health. These actors bring diverse resources, capabilities, and infrastructure. WHO is currently working to fully adopt the Framework for Engaging with Non-State Actors (FENSA) (WHO, 2015i). FENSA is intended to promote engagement among WHO and non-state actors and encourage non-state actors to use their own activities to protect and promote public health. Building on FENSA, WHO CHEPR should actively engage non-state actors, especially local and international civil society organizations, the private sector, and the media.
Local and International CSOs
As noted in Chapter 3, local and international CSOs—such as community-based, nongovernmental, and faith-based organizations, as well as academic and research institutions—often have a valuable grasp of the realities on the ground and a vital role to play in ensuring that the perspectives of those directly affected by outbreaks are heard. Working closely with anthropologists with long-term knowledge of affected regions or subject specific knowledge can be a particularly effective way of not only identifying local and regional challenges to containing outbreaks, but also finding locally acceptable and practical solutions to complex issues emerging on the ground. Representatives from civil society could help WHO with reporting of cases, adapting and readjusting approaches during disease outbreaks, realigning priorities, and establishing and disseminating standards, such as those related to research. Moreover, CSOs should be encouraged and supported to play advocacy and watchdog roles at country and global levels. They have demonstrated the ability to bring issues of global and national concern to the forefront, capturing the attention of political leaders and funders, as exemplified in the case of HIV/AIDS (UNAIDS, 2012). WHO should develop protocols and build formal and genuine relationships with local and international civil society groups so that both sides know when and how these actors can contribute most effectively.
The private sector has traditionally provided funding and supplies during emergencies, but private companies have a broad range of other assets, expertise, and capabilities
that can augment the public-sector response. The private sector can bring expertise and resources to help with research and development of medical products, transportation of supplies, educational campaigns, construction of treatment units, development and deployment of innovative technology and infrastructure to support responses, logistics and supply chain issues, data management, and financial services (WEF, 2015).
However, private-sector players often do not know the best ways to help, so their contributions have often been ad hoc and inconsistent. WHO CHEPR should build relationships with private companies to harness their capabilities in the event of a public health emergency. The key is to define roles and mechanisms for coordination. The private sector must be informed of priorities in order to align its efforts with the UN and WHO, other companies, governments, and other non-state actors. For example, WHO should engage with airline and trade industries so that their actions align with the IHR as much as possible. With such relationships and alignments in place, companies would know how to contribute effectively and exchange information smoothly with WHO CHEPR and other actors in the event of an outbreak.
The media plays a critical role in communicating to the public about an outbreak. In order to communicate effectively—with the goal of promoting safe behaviors and controlling the spread of the disease—messages must be unified, accurate, evidence-based, well-framed, and timely. The most important aspect of good communication is openness and transparency, which will help gain the trust of the public. When messages are poor, they can create or exacerbate mistrust, generate anxiety, and foster rumors and conspiracies. These outcomes may inadvertently encourage behaviors that make a difficult situation even worse. To prevent this from happening, WHO CHEPR should ensure that it has staff with anthropological, social media, and crisis communication expertise who can work closely with media agencies.
Recommendation C.6: By the end of 2016, the World Health Organization and national governments should enhance means of cooperation with non-state actors, including local and international civil society organizations, the private sector, and the media.
WHO should redesign processes and protocols to reinforce the effectiveness of the IHR. In Chapter 3, the Commission recommends that WHO devise a regular independent, transparent, and objective assessment mechanism to evaluate country performance. In this section, we go further to recommend mechanisms that would help ensure that countries report cases and facilitate appropriate international response. We also comment on the type of leadership needed to ensure that such changes are made and sustained.
A High-Priority “Watch List” of Outbreaks
One of the main responsibilities of WHO CHEPR should be to ensure that outbreaks are properly detected and prioritized. Currently, there are some mechanisms in place that aim to fulfill this function. For instance, at national focal points (NFPs), health officials are expected to notify and report potential PHEICs to WHO under the IHR decision instrument for notifications, which member states are required to use. Furthermore, the WHO Global Alert and Response team8 meets each weekday morning to review incoming reports from official and unofficial sources for suspected outbreaks and unknown diseases and for outbreaks undergoing verification and containment. The team then decides on the actions needed for these reports. If a notification has been deemed a potential PHEIC, WHO is expected to provide NFPs with timely updates through a secure event information site (EIS) (WHO, 2008). If a notification is deemed internationally significant,9 the WHO DG convenes an emergency committee of subject-matter experts who provide advice and recommend an evidence-based response. Emergency committees typically make recommendations about whether to declare a PHEIC, but the ultimate decision rests with the DG.
Despite these mechanisms, countries are often reluctant to report novel infections. A major reason is that
9 This is based on six main criteria: (1) unknown disease; (2) potential for spread beyond national borders; (3) serious health impact or unexpectedly high rates of illness or death; (4) potential for interference with international travel or trade; (5) strength of national capacity to contain the outbreak; and (6) suspected accidental or deliberate release (WHO, 2015b).
reporting could be seen as failure in the countries’ surveillance or the wider global alert and response program (IOM and NRC, 2009). Thus, reporting has implications for national prestige and reputations. Moreover, news of a potential PHEIC can sometimes provoke excessive responses such as travel and trade restrictions, which can adversely impact a state’s economy. However, the Commission stresses that it is vital to instill the global norm of early detection and rapid reporting of potential PHEICs. Delayed reporting can cause grave consequences, as some outbreaks need immediate attention to prevent them from becoming epidemics and even pandemics. Prompt alerts enable swift, early, and strong response, which can save lives and money.
To instill the norm of early reporting and encourage necessary preparedness activities for potential PHEICs, the CHEPR should identify and communicate to NFPs the top priority outbreaks that have the potential to become a threat and need careful monitoring. This “watch list” should be drawn from the daily reports the CHEPR receives from official and unofficial sources and should be prioritized based on a rigorous and transparent risk assessment. The CHEPR should communicate the priority watch list through the EIS every day, so that regions and countries could not only see what the CHEPR is monitoring, but also access information to help them ascertain the degree to which interventions and resources should be mobilized. Through this mechanism, alert and response teams at all levels would be better prepared and more easily held accountable. For example, if a high-priority outbreak remained on the list for a while without any response from the affected country, the WHO CHEPR could step in and facilitate technical support as necessary. A summary of this priority watch list should also be made public through the WHO website, perhaps on a weekly basis. We recognize that publishing lists of potential PHEICs might trigger overreaction and public fears. However, if such a list were published every day, it would quickly become normalized and would destigmatize the reporting of outbreaks.
Recommendation C.7: By the end of 2016, the World Health Organization (WHO) should establish a mechanism to generate a daily high-priority “watch list” of outbreaks with potential to become a Public Health Emergency of International Concern to normalize the process of reporting of outbreaks by country and encourage necessary preparedness activities. WHO should communicate this list to national focal points on a daily basis and provide a public summary on a weekly basis.
Protocols for Holding Governments Publicly Accountable
Because of the critical consequences of delayed or non-reporting, WHO CHEPR should create a mechanism to hold accountable countries that try to suppress or delay reporting. Countries that share information quickly should be lauded and supported (for example, through budgetary assistance from the IMF, as discussed later in this chapter). Countries that are not transparent and forthcoming in their notifications should be publicly named. In both instances, the WHO weekly epidemiological report should contain details on how a report was obtained and appropriate commendations.
Similarly, the CHEPR should create protocols to dissuade member states and the private sector from implementing unnecessary restrictions on trade and travel. In past outbreaks, many countries and airline carriers restricted travel, commerce, and trade. Although there are strong political motivations for harsh measures, the IHR create binding legal obligations to act in an evidence-based manner, following WHO’s recommendations regarding “additional measures.” Travel restrictions can be highly counterproductive. When borders close and commercial flights discontinue, global actors have difficulty providing essential resources to the affected areas, delaying response efforts and sometimes creating an even greater humanitarian and health care emergency (Heymann et al., 2015). Further, travel restrictions could drive affected patients underground, making it challenging to deliver treatment and potentially allowing the disease to spread more rapidly in the isolated area—eventually putting surrounding areas at even greater risk. It is also worth noting that some borders are difficult to regulate, meaning travel restrictions may not effectively contain the disease. Thus, although travel bans offer an illusion of safety, they also lead to prejudice and stigma around those in affected areas and delays in robust response efforts.
To prevent travel bans, relevant stakeholders, such as the International Air Transport Association and the World Trade Organization, should be engaged prior to the next outbreak. Strong understanding and communication of the consequences of travel restrictions, as
well as cooperation among relevant stakeholders and the public, is crucial. If travel bans are implemented without scientific justification, protocols such as publicly disclosing those countries should be established.
Recommendation C.8: By the end of 2016, the World Health Assembly should agree on new mechanisms for holding governments publicly accountable for performance under the International Health Regulations and broader global health risk framework, as detailed in Recommendation B.2, including:
- protocols for avoiding suppression or delays in data and alerts, and
- protocols for avoiding unnecessary restrictions on trade or travel.
Creating a well-resourced CHEPR, establishing the CFE, and reinforcing coordination and alert mechanisms would enable WHO to be a more effective leader in pandemic preparedness and response. However, the Commission recognizes that strong individual leadership by the DG is also essential. The DG must have the right personal attributes and must be empowered by member states to use them. As the next DG election approaches, member states should carefully consider the leadership qualities that will enable WHO to fulfill its vital role within the global health risk framework. These attributes include:
- the ability to reenergize and refocus the organization around its core priorities, making it simultaneously more effective and efficient;
- the relationship-building and influencer skills needed to build constructive relationships with other actors, such as other multilateral agencies and non-state actors; and
- the stature and courage to hold their own with other global leaders, to accept accountability, and to hold countries accountable.
For their part, member states must give the DG the resources and support to enable effective global leadership, even when this entails making tough trade-offs, standing behind unpopular decisions, and calling individual countries to account.
When an infectious disease outbreak has the potential to become an epidemic or pandemic, speed of response is vital. This means mobilizing financial resources swiftly to support the overall response strategy. For many countries, the government’s own contingency resources will be the primary source of such funds; however, in situations where challenges overwhelm domestic resource capabilities, international financing support is needed. The experience of Ebola demonstrated that mobilizing such contributions can take time, so it makes sense to have contingency financing arrangements in place to ensure a rapid and effective response. Moreover, the availability of such contingency support arrangements could help to mitigate incentives to delay or suppress alerts at the national level. As discussed earlier in this chapter, WHO’s CFE represents one source of such emergency funding, but at $100 million, it is of quite limited scale. To mobilize financial resources of greater scale requires that the World Bank and the IMF also have appropriate arrangements.
An Emergency Contingency Fund for Pandemic Response
The Commission welcomes the World Bank’s creation of the PEF, because, given the nature of pandemics, it is essential that significant external resourcing can be made available without delay. Although the governments of high-income countries and other donors would undoubtedly respond again to assist a low-income country, the Ebola experience illustrates that mobilizing such resources can take considerable time given considerations such as legislative approval. In our view, the PEF should be the second source of immediate funding from international sources, following quickly on the heels of WHO’s CFE. Although there is no precise science to determining the size of the PEF, the figure of $1 billion seems not unreasonable.
It could be argued that rather than having both a CFE and PEF, there should be only one fund. However, the Commission believes these two funds serve distinct and complementary purposes. The CFE is designed to enable WHO itself to respond quickly and flexibly to outbreaks with pandemic potential. This fund is deliberately discretionary to maximize flexibility and speed of
response. It is also constrained to funding WHO’s activities. The PEF would be triggered less often and with less discretion but would deploy far greater funds to a broad array of accredited responders (including WHO). Merging the CFE and the PEF would limit the DG’s flexibility and slow disbursement. Extending the CFE to encompass the greater scale and scope of the PEF would require WHO to fund third parties at a scale it cannot manage. Such funding is already a core function for the World Bank. Creating a separate entity would simply add cost and bureaucracy. That said, it is clearly important that WHO and the World Bank work closely together to optimize the deployment of the CFE and PEF. Indeed, they will also have to coordinate with other contingency funding arrangements within the UN system, such as the CERF.
The need for the PEF to be available quickly after an outbreak has been identified as having pandemic potential is an important consideration in determining the appropriate financing mechanism. There are a number of options.
Option 1: One-Off Cash Contributions or Binding Contingent Commitments from Member States of Other Donors
This option has the advantages of immediacy and certainty. Where cash has been contributed, it will be immediately available. Where a commitment is in the form of a binding contingent commitment, the World Bank will be able to raise funds quickly and cost-effectively from the capital markets against that commitment. The disadvantage of this option is that it would require further support from governments of advanced economies and donors, some of whom may not be able to operate on a contingent commitment basis due to constitutional or other legal constraints (although there may be scope to devise near legally-binding contingent commitments, structured so that they can be made binding extremely rapidly). In principle, this approach simply brings forward and makes much more efficient the usual process of calling on advanced economies and other donors when a crisis occurs. However, the political reality of asking governments to contribute or commit substantial sums before a crisis is in sight makes this option quite challenging.
Option 2: Insurance
Pandemic insurance is certainly worth pursuing, and considerable progress has been made in developing this option. The key will be whether it will prove cost-effective and practical. To be cost-effective, disaster insurance of this kind typically needs an objective parametric trigger (e.g., an earthquake, or rainfall below a certain amount). Discretionary triggers tend to result in much higher premiums. Given the uncertainties that inevitably surround the early phases of an infectious disease outbreak, this is somewhat problematic. By the time it is objectively clear that a pandemic is taking place (e.g., via a clear impact on mortality data), it may be too late. We are aware that considerable progress has been made in defining and agreeing potential triggers, but the test will be how these work well in practice.
There are three other issues that need to be considered. Given that life insurers and their reinsurers already bear mortality risk relating to pandemics and hold capital against extreme changes in mortality risk, it can be argued that they should be trying to reduce the extreme mortality risk in their balance sheets. This would suggest they should be prepared to pay for a response mechanism like the PEF that reduces the risk of an outbreak turning into a pandemic, rather than be paid for it. This is the logic underpinning the idea discussed in the next chapter on financing research and development. If insurance regulators were prepared to recognize that financing the PEF would reduce the mortality risk that insurers face, then it might be possible to fund the facility much more cost-effectively. At the very least, these considerations should be factored into the pricing negotiations.
Additionally, to the extent that insurance premiums are paid by advanced economies and donors on behalf of low-income countries, one must consider whether this is the best use of constrained overseas aid budgets. Paying such premiums might save the advanced economies from having to offer support should a pandemic occur, but would do little to change the reality and the risks for the country itself. It may be better to spend the money on helping to rectify gaps in health system capabilities.
On the other hand, a clear benefit of using insurance for the PEF is that involvement of the private sector typically drives an intense focus on improving data and can create powerful incentives to mitigate risk—and may ultimately catalyze the development of a private market in pandemic insurance. These dynamics constitute pow-
erful arguments for pursuing insurance options. Better data gathering and modeling will certainly contribute to better preparedness. Creating stronger incentives for governments to invest in pandemic preparedness is certainly desirable. However, it should also be noted that incentives are different with pandemics. For other kinds of natural disasters, such as earthquakes or drought, afflicted countries have to rely on altruism when seeking external support. There is no powerful externality. When a potential pandemic occurs, other countries will help out of self-interest, not just altruism—and this means there is less incentive to pay for insurance. The challenge of defining a clear event and the impact of externalities on incentives suggest we may need to be cautious about the prospects of developing a private market in pandemic insurance.
Option 3: Pandemic Bonds
Pandemic bonds work almost like pandemic insurance in reverse, but are addressed to different investors. With pandemic insurance, one pays a premium and gets a cash payout if a pandemic occurs. With pandemic bonds, an investor issues a bond in exchange for cash and extinguishes the debt if a pandemic takes place. As with pandemic insurance, the challenge is whether it is possible to identify a trigger that is both objective and early. Extreme mortality bonds, from which pandemic bonds are derived, are triggered by defined changes in mortality. In the case of a pandemic, this trigger would be too late for the purposes of the PEF. As with insurance, for pandemic bonds to be cost-effective as a funding mechanism for the PEF, it will be necessary to identify triggers that are simultaneously parametric and early. We understand that this is precisely what the World Bank and its private-sector partners have been working together to achieve.
Assessing the Options
Given these considerations, the Commission thinks that Option 1 would be the optimal way to finance the PEF if economic efficiency were the only consideration. However, we acknowledge it will be difficult to secure financial commitments of this magnitude and to overcome the legal constraints on contingent commitments that some governments face. We also recognize the broader benefits of engaging the private sector on data analytics and incentives. If the pricing of the innovative solutions in Options 2 or 3 can be made economically attractive, then it might be possible to combine these options, using funds from Option 1 as the early-release component and funds from Options 2 and 3 somewhat later. With such a combined structure, it would be important to ensure that the pricing of the insurance and bond components reflects the fact that they benefit from the existence of the component of the PEF funded by Option 1.
Recommendation C.9: By the end of 2016, the World Bank should establish the Pandemic Emergency Financing Facility as a rapidly deployable source of funds to support pandemic response.
Emergency Budgetary Assistance
The WHO CFE and the World Bank PEF are designed to fund emergency response, rather than offset the economic impact of a crisis. The feasibility of developing financial mechanisms to mitigate broader economic impacts on an afflicted country is often discussed, not least because concerns about potential economic consequences can lead governments to delay reporting. However, it is difficult to see how either the insurance industry or capital markets could provide cost-effective mechanisms to achieve this objective, given the potential scale of the impact, the difficulty of establishing objective early triggers, and the degree of perverse incentives.
Yet it would make sense for the IMF to consider revising eligibility and triggers for the Rapid Credit Facility (RCF) to ensure it is clear that this facility is available to provide budgetary assistance for countries reporting infectious disease outbreaks. The RCF is designed to provide rapid concessional financial assistance with limited conditionality to low-income countries facing an urgent balance-of-payments need (IMF, 2015). The RCF streamlines the IMF’s emergency assistance, provides significantly higher levels of concessionality, and can be used flexibly in a wide range of circumstances. While the RCF could not offset the entire economic impact a country facing a potential pandemic, it could help ease the pressure on the government of a low-income country faced with rapidly escalating spending requirements and plummeting tax revenues. Moreover, this could make it clear that declaring an outbreak to have epidemic or pandemic potential might help mitigate the incentives to delay such a decision.
In addition, although insurance is unlikely to provide
a complete answer, national governments might want to encourage critical industries to take out appropriate business interruption insurance to mitigate the direct impact on individual firms and thus on the economy as a whole. Levels of business interruption insurance coverage in many countries appear remarkably low (Swiss Re, 2015).
Recommendation C.10: By the end of 2016, the International Monetary Fund should ensure that it has the demonstrable capability to provide budgetary support to governments raising alerts of outbreaks, perhaps through its existing Rapid Credit Facility.
Strengthening international coordination and capabilities is vital to countering the threat of infectious diseases on a global scale. The recent Ebola outbreak revealed significant shortcomings in WHO’s operational capacity and leadership, as well as in timely disbursements of funds and resources. To reinforce international coordination and capabilities for outbreak preparedness, alert, and response, WHO should play a leading role in the global system by creating a well-resourced center overseen by a TGB and improving coordination with other global actors, including other UN agencies, regional networks, civil society organizations, and the private sector. There is also a need to redesign protocols to incentivize reporting of outbreaks and encourage necessary preparedness activities. Finally, the development of contingency support arrangements is essential to ensure that a rapid and effective response is not hindered by lack of funds. Global actors together must carry out these critical functions to effectively prepare and respond to major infectious disease outbreaks. The next chapter discusses the need to accelerate R&D to counter the threat of infectious diseases.
Essential Functions for Effective Outbreak Preparedness and Response
Global actors must carry out several essential functions for effective outbreak preparedness and response (see Table 4-2). These functions can be divided into three major categories.10 The first overarching category encompasses functions related to the management of externalities across countries to prevent or mitigate deleterious health effects that arise from one country and might affect another. This effort requires strong coordination among stakeholders to ensure timely response to threats that spread across borders. In recent years, the global health landscape has expanded to include multiple actors ranging from national governments, the UN system, multilateral development banks, public–private partnerships, and international and local civil society organizations to the private sector. While these transformations have opened doors to different and innovative resources, coordination of these multiple actors has become particularly important and challenging in responding to a PHEIC. If actors and efforts are uncoordinated and unchecked, competition, duplication, and poor quality tend to emerge.
Another overarching category is the production of global public goods, particularly knowledge-related goods. In the context of infectious disease outbreaks, examples include defining and evaluating standards for national core capacities and setting priorities for research and development of medical products, among others. This would help global actors work together to achieve common goals in an efficient and accountable way.
Finally, there is a need to mobilize aid to areas where national governments are unwilling or unable to provide protection. For example, when an infectious disease outbreak occurs in a fragile state, financial and resource support will be needed. Even outside fragile states, there may be cases when a country is acutely overwhelmed by a crisis. In these cases, the deployment of emergency response funds and technical cooperation from the international community may be needed. At present, there has been conversation about the creation of emergency response funds at WHO and the World Bank, but no mechanisms have been put into place.
It is important to note that for these functions to perform well, good governance must be observed. Good governance for global health is accountable, transparent, responsive, equitable and inclusive, effective, efficient, and participatory (Gostin, 2014), and should extend from local communities to multinational organizations. However, achieving this ideal can be challenging in the context of infectious diseases because they can evolve into a broader social crises, drawing in political processes and leaders. These officials have the ultimate responsibility for ensuring not only needed health care but also all other services expected of governments before, during, and after crises. Hence, governance for global health needs to integrate a broad array of technical and political inputs. The foundation should be scientific, but the ultimate accountability lies in the political domain. A challenge for the design of systems of governance for global health is to coordinate these accountability functions in such a way that they remain distinct, but are also synergistic. A hierarchy of power and authority needs to be designed such that the best technical advice effectively and efficiently serves the operational and political.
WHO’s Strengths and Weaknesses as the Global Leader in Pandemic Prevention and Control
WHO’s constitution mandates that it be the global health leader in disease surveillance, outbreak investigation, and response.11 In fact, the primary rationale for establishing WHO in 1948 was to control cross-border infectious diseases. To facilitate the management of PHEICs, WHO may use legal and technical tools to set international norms and guidelines for member states in preventing and responding to potential PHEICs. For
TABLE 4-2 Essential Functions for Outbreak Preparedness and Response at the Global Level
|Categories of Essential Functions||Sub-Functions||Examples Specific to Outbreak Preparedness and Response|
|Management of externalities across countries||Coordination for preparedness and response and deployment of surveillance and information sharing||
Coordination and communication within and among stakeholders for preparedness and response, including:
Reinforce system for coordinating response to alerts/ outbreaks (e.g., Global Outbreak and Response Network, global health workforce, emergency operations centers, plans for joint readiness exercises, laboratory networks that meet a standard of accreditation, equitable distribution of medical products, etc.)
|Production of global public goods||Development of international standardization, priority and rule setting, guidelines regarding best practices, and evaluation of actors and actions||
Define standards for national core capacities (not just the IHR, but also incorporating key elements of GHSA), including measurable metrics
Develop guidelines for best practices in reinforcing national core capacities
Create system of independent, objective, and transparent assessment of national core capacities, including response plans (akin to GHSA assessment process), so that governments can be held accountable
Set priorities for R&D of medical products
Establish standards and agreements for R&D issues (e.g., not nationalizing vaccines during emergencies)
|Mobilization of global solidarity||Provision of aid, including development financing, technical cooperation, humanitarian assistance, and agency for the dispossessed||
Provide financial support to low-income countries seeking to enhance national core capacities
Provide financial and other resource support for failed states
Develop and deploy emergency response funds
NOTE: FAO = Food and Agriculture Organization of the United Nations; GHSA = Global Health Security Agenda; IHR = International Health Regulations; OIE = World Organisation for Animal Health; PHEIC = Public Health Emergency of International Concern; R&D = research and development; UN = United Nations; WHO = World Health Organization.
SOURCE: Framework adapted from Frenk and Moon, 2013.
example, the IHR allow WHO to work with affected countries in outbreak investigation, assess the risk, and facilitate timely declaration of the status of the outbreak.12 Additionally, many resolutions developed by the WHA, which convenes health ministers from 194 member states, request WHO to work on PHEICs as well as capacity building for epidemic and pandemic response. These requests show the authority and legitimacy that WHO already holds in this area.
Further, WHO has social credibility as the leading agency to manage global health issues, especially epidemics and pandemics. Past successes in controlling several high-profile infectious diseases, including plague, smallpox, and malaria, have made WHO a highly socially respected organization when it comes to dealing with disease outbreaks. In 1966, WHO initiated action to carry out a worldwide smallpox eradication program. Historically, the program remains one of the greatest achievements of WHO. Although the 2009 H1N1 pandemic and recent Ebola outbreak may not be good success cases for WHO, it nevertheless continues its role as global health leader.
WHO also has a wide network that allows it to work closely with various actors on outbreak preparedness and response. Within its organization, WHO has an extensive network of 6 regional and 145 country offices. WHO has strong linkages and close collaboration with agencies responsible for preparedness and response in member states, as well as access to thousands of the best public health experts around the world. Additionally, WHO actively engages with various UN mechanisms, which are key drivers in humanitarian crises, including the UN Office for the Coordination of Humanitarian Affairs (OCHA), the UN Executive Committee on Humanitarian Affairs, the Global Humanitarian Platform, the UN Economic and Social Council, and other initiatives and entities as relevant to play major roles in health cluster–related issues. WHO also engages in dialogue with all stakeholders involved in humanitarian assistance and works to keep health high on the political/humanitarian agenda. Outside the UN framework, WHO cooperates with a wide network of humanitarian partners worldwide, including the Red Cross and Red Crescent movement, Collaborating Centers, universities and other academic institutions, CSOs, and senior public health experts. Other key partners are intergovernmental institutions such as the African Union, the Council of Europe, and the International Organization of Civil Protection.
Although WHO must lead the effort in outbreak preparedness and control, it currently lacks the organizational capacity to deliver a full emergency public health mechanism (see Table 4-3). With its bureaucratic and vertical structures, WHO cannot perform efficiently. For example, overall coordination among the headquarters and regional offices is poor (WHO, 2013). The separation of humanitarian and outbreak control work has led to confusion and duplication of activities.
Additionally, WHO predominantly works with the ministries of health for each country, and not as much with other actors. Although it does have channels to work with CSOs and the private sector, coordination and engagement could be improved, especially as the number of actors in the global health landscape increases. Working with other actors is crucial to expand WHO’s capacity to manage emergencies and other difficult and complex health problems. Such capacity is becoming more important in the past few decades when health issues have been linked to complex socio-economic and political issues.
Political undercurrents influence global health issues. This is not surprising, as health has come to be thought of
12 In the IHR (2005), Article 13 notes the following: “(3) At the request of a State Party, WHO shall collaborate in the response to public health risks and other events by providing technical guidance and assistance and by assessing the effectiveness of the control measures in place, including the mobilization of international teams of experts for on-site assistance, when necessary. (4) If WHO, in consultation with the States Parties concerned as provided in Article 12, determines that a public health emergency of international concern is occurring, it may offer, in addition to the support indicated in paragraph 3 of this Article, further assistance to the State Party, including an assessment of the severity of the international risk and the adequacy of control measures. Such collaboration may include the offer to mobilize international assistance in order to support the national authorities in conducting and coordinating on-site assessments. When requested by the State Party, WHO shall provide information supporting such an offer” (WHO, 2008). Further, in Article 49, it says “(6) The Director-General shall communicate to States Parties the determination and the termination of a public health emergency of international concern, any health measure taken by the State Party concerned, any temporary recommendation, and the modification, extension and termination of such recommendations, together with the views of the Emergency Committee. The Director-General shall inform conveyance operators through States Parties and the relevant international agencies of such temporary recommendations, including their modification, extension or termination. The Director-General shall subsequently make such information and recommendations available to the general public” (WHO, 2008).
TABLE 4-3 Strengths and Challenges of WHO as the Role of Health Cluster Lead in PHEICs
|1. WHO’s roles and mandate for PHEICs are clearly identified (by constitution and the IHR)||
1.1 WHO’s bureaucracy and capacity need to be much improved to respond to such a huge mandate.
1.2 There are other agencies with competing roles, and WHO should collaborate with them.
|2. Legal and technical tools (e.g., IHR)||2.1 WHO governing structures are vertical and bureaucratic and have inadequate capacity to fully implement the legal and technical tools.|
|3. WHO’s social credibility and capacity||
3.1 WHO is facing challenges to recruit and maintain capable staff; this threatens its social credibility.
3.2 WHO’s bureaucratic governance systems limit its collaboration, mainly with the public sector.
3.3 Health issues become more and more politicized.
|4. WHO’s own financial resources, based on assessed contribution||4.2 The assessed contribution is becoming a smaller and smaller proportion of the WHO budget, and thus WHO has less freedom in its spending.|
NOTE: IHR = International Health Regulations; PHEIC = Public Health Emergency of International Concern; WHO = World Health Organization.
as a tradable commodity (Labonté and Gagnon, 2010). However, politicizing the health discussion in WHO has gradually eroded the most important social asset of the organization—that is, trust among its members. As trust dwindles, it has become more difficult for WHO’s networks and member states to work together to fight potential pandemics. There is fear that political influences shroud decisions that are ostensibly based on technical expertise.
Finally, WHO has had limited freedom in how it uses resources. Since the early 1990s, WHO has depended more on voluntary contributions. Voluntary contributions have become its main source of income, accounting for 80 percent or more of its expenses, and are earmarked so that WHO does not have much control over how to use the funds (WHO, 2014).
As these challenges reveal, WHO’s performance in preparedness and response for PHEICs needs improvement. Decisions should be based on rigorous scientific input and shielded from major political interferences. WHO also needs to become more nimble and proactive, breaking down vertical or duplicative structures and providing robust and flexible operational capacity. Finally, an accountability mechanism is needed to evaluate and enhance WHO’s performance.
Four Potential Models of Governance for Global Health Security
The Commission considered four models of governance for global health security.13 These models are neither mutually exclusive nor exhaustive of all possibilities for global health governance. All of these models recognize that business as usual is not an option.
Model A: A Reformed WHO14
This model assumes that WHO would continue to have operational responsibility for outbreak preparedness and response through improvements of existing structures. Reforms may include distinctly separating technical departments and those dealing with governance; limiting the position of the DG to a single term; modifying the structure and staffing requirements of regional and country offices; and adjusting funding arrangements to ensure that WHO can fulfill core functions. These re-
13 These models were presented at the Institute of Medicine Workshop on Governance for Global Health on September 2, 2015. For more information, see http://iom.nationalacademies.org/Activities/PublicHealth/MicrobialThreats/2015-SEP-01.aspx (Accessed February 1, 2016).
forms rely on the member states to be motivated to push for fundamental reform.
Model B: WHO Plus15
This model proposes that WHO would continue to have operational responsibility for outbreak preparedness and response but would significantly revamp its organizational and operational capacity to deliver a complete emergency public health response. To achieve this, WHO would create a center for humanitarian and outbreak management attached to WHO and under the authority of the DG that combines strategic, operational, and tactical capabilities for emergency, humanitarian, and the IHR functions. This center would be designed to respond quickly to different kinds of outbreaks and emergencies. The routine and crisis modes, and the transition between them, would be governed by the center’s director, in consultation with the DG, and guided by an independent board in such a way as to create transparency and ensure effectiveness. The center would also strengthen coordination across all three levels of WHO as well as with the UN humanitarian system. In order to support this activity, an increased health security budget within WHO, as well as an increased political commitment from member states, would be required.
Model C: The Executive Agency Model
In this model, the UN system would create an enabling environment in which WHO, potentially through a center for humanitarian and outbreak management, takes the lead in the health sector and executes a strategic operational and tactical role in a health emergency. This model aims to take advantage of WHO’s expertise and legitimacy, while allowing it to tap into the UN’s higher level of authority for command and control and political support. This model would be activated only when a multisectoral global response is required to reduce health risk.16 These reforms rely on WHO to formally coordinate with UN programs and funds under the framework of OCHA and harmonize with NGOs under the IASC framework.
Model D: A New, Separate Entity Under the UN
This model assumes that the current mandate on global health risks contained in WHO’s constitution is either unclear or insufficient and that WHO cannot or should not deal with global health risks. Rather, outbreak preparedness and response measures should be drawn from other UN-system assets and authorities. In effect, the UN would create an interagency entity for global health risks, under the UNSG. This entity would encompass capabilities not only from WHO but also from the FAO, UNICEF, the United Nations Development Programme, World Food Programme, and others.
Models for Reforming WHO’s Work on Outbreak Preparedness and Response
Since the Ebola crisis, several initiatives have proposed different types of models for reforming WHO’s work on outbreak preparedness and response. Each initiative recognizes that WHO must strengthen its capacity during outbreaks and that the health emergencies and outbreak response functions should merge. Additionally, the initiatives urge better integration of these functions across all three levels of WHO, as well as some kind of oversight mechanism. However, each proposal also suggests different elements for the operational entity’s governance and funding structure (see Table 4-4).
16 For example, in cases when an infectious disease is known and the national capacities are fragile, or when the disease is unknown and the national capacities are low, a multisectoral development response would be required within the UN Development Assistance Framework, with WHO taking the lead in the health sector. Alternatively, in cases when the infectious disease is unknown and national capacities are fragile, OCHA would coordinate a multisectoral humanitarian response, with WHO taking the lead in the health cluster (NASEM, 2016).
TABLE 4-4 A Comparison of Proposed WHO Reform Models for Outbreak Preparedness and Response
|Initiative||Center/Program||Declaration of PHEIC||Role of the United Nations||Oversight Mechanism||Funding|
|WHO’s Ebola Interim Assessment Panel||Center for Health Emergency Preparedness and Response, led by an ED who reports to the DG||DG supported by Emergency Committee, with introduction of an intermediate level PHEIC option that can be declared at an earlier stage of crisis ahead of a full PHEIC||When a crisis escalates to a point where it poses a high-level global health threat requiring greater political and financial engagement, the UNSG should consider the appointment of a Special Representative of the UNSG or a UN Special Envoy with a political and strategic role to provide greater political and financial engagement||An independent board would guide the development of the center and report on its progress to the WHO Executive Board, WHA, and the UN IASC||Increased assessed contributions by 5 percent|
|Harvard Global Health Institute and London School of Hygiene & Tropical Medicine’s Independent Panel on the Global Response to Ebola||Center for Emergency Preparedness and Response, led by an ED who reports to the DG and Board of Directors||A newly developed WHO Standing Emergency Committee, chaired by DG||If initial response does not succeed and an outbreak becomes a humanitarian crisis (threatening not only public health, but also political, economic, and social stability), OCHA should provide third line of defense. Also the UN should appoint an “accountability commission,” and the UN Security Council should establish a global health committee||A Board of Directors would oversee the center. Members would include broad representation of governments from each WHO region, scientific expertise, operational responders from all sectors, and funders||Protected and adequately resourced through a dedicated revolving fund Standing Emergency Committee is funded by assessed contributions to protect against undue donor influence|
|WHO’s Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies||Programme for Outbreaks and Emergencies Management, led by an ED who reports to the DG||Not specified, most likely DG||The UN and the WHO Program should work closely to build mechanisms to enhance surge capacity. In many instances, WHO will act as part of a larger UN Humanitarian Country Team||External, independent oversight body established by the DG would monitor performance of the Programme (and operational platform). May report to the WHO Executive Board, WHA, and UNSG||Steady-state financing; will explore options to increase allocations for the core budget of WHO so the Programme can receive predictable funding|
NOTE: DG = Director-General; ED = Executive Director; IASC = Inter-Agency Standing Committee; OCHA = UN Office for Coordination of Humanitarian Affairs; PHEIC = Public Health Emergency of International Concern; UN = United Nations; UNSG = UN Secretary-General; WHA = World Health Assembly; WHO = World Health Organization.
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