MANILA — In 2014, the world was plunged into panic when the Ebola virus spread across countries in West Africa, killing thousands. When the crisis waned, much of the criticism fell on the World Health Organization for its initial response and lack of preparedness. The agency pledged to do better and launched a new Health Emergencies Programme that would operate coherently across the three levels of the organization, with a clear set of structure, processes and lines of authority.
Fast forward to 2017, and the program has made progress in making this a reality, according to a new report by the Independent Oversight and Advisory Committee. The independent body is tasked to monitor and assess WHO’s performance in implementing the program, and presented its report to member states at the 142nd executive board session in Geneva.
How does the World Health Organization run during emergencies and outbreaks? Devex spoke with Wynne Boelt, communications officer for WHO's Health Emergencies Programme, to learn more about the aid agency's incident management system.
The health emergencies program’s structure is now aligned across the three levels of WHO, according to the report, and that there’s been “significant progress” in the speed in which WHO assesses public health events. The organization has introduced various tools, such as an emergency dashboard, to help senior leadership make informed decisions on how to better coordinate responses. The director-general has also made it his mission to be on top of emergency situations through daily briefings and a health security council that meets fortnightly.
Some of WHO’s partners on the ground have also provided the organization positive feedback, including in providing technical and operational support. The IOAC commends the program for engaging in what it calls “innovative partnerships.” The program is part of a new humanitarian mechanism run together with UNICEF, Médecins Sans Frontières, and Save the Children that has so far helped provide 360,000 children access to pneumococcal vaccine during humanitarian emergencies in the Central African Republic, Democratic Republic of the Congo, Lebanon, Niger, Nigeria, and South Sudan.
But significant challenges remain, says the IOAC.
Not all staff are aware of how the program functions, nor are a number of government and WHO partner agencies. WHO’s own systems and processes also continue to contribute to delays in recruitment, procurement, and contracting of implementing partners.
The IOAC attributes delays in recruitment on funding uncertainties and a lack of dedicated HR staff for the program, with the latter adding extra work to emergency staff and managers at country level. In its field visits in Iraq, Mali, Nigeria, and Pakistan, for example, the committee found incident managers or country representatives having to take on HR work in selecting suitable candidates, while program staff are tasked with developing job descriptions, candidate screening and shortlisting, and drafting of interview questions.
Another source of concern for the committee is WHO’s lack of a fully integrated global supply chain management system, making it difficult to manage and do inventory on what and how much stocks of particular drugs, medical devices or emergency kits are in a particular warehouse in each country.
The program encounters similar issues when it comes to vetting partners at country level.
“WHO must redo the due diligence process for a country-level partner each time new funding is issued, even if that partner has already been vetted at the country or global levels, or already has an existing WHO grant,” according to the report.
The program has set standard operating procedures that include, for example, simplifying procurement processes in the case of emergencies, but some staff, including those on the lines of authority, are unaware of these. Emanuals sent to staff members do not help much as staff don’t read them, or find difficulty in understanding the process.
Who is in charge of what is sometimes unclear. For example: Whose authority it is to approve a particular financial transaction, or whether country representatives can participate in fundraising. The IOAC however notes it has observed recent efforts by the organization to clarify responsibilities in its missions in Mali and Nigeria.
Security is another area of concern. Program staff, like other United Nations aid agencies and nongovernmental organizations, also work in areas with high levels of security risks, but the committee observed that the security support given to staff is “inadequate” in relation to the size of WHO presence in the field.
“WHO is advised to put in place a coherent strategy and investment for security as a matter of urgency,” according to the report. “The IOAC reiterates that this will be critically important in
view of WHO’s responsibility given the increasing number of deployments of staff and partners.”
But financing is a critical concern.
A significant amount of the funding for the WHO Health Emergencies Programme is earmarked, meaning the program is unable to allocate it as needed. It may have attracted as much as $1 billion in its infancy, but now its coffers are almost empty, says the committee.
The Contingency Fund for Emergencies, set up by the World Health Assembly as a readily available source of funding for WHO in case of disease outbreaks and health crises, is also “drying up,” said WHO Director-General Tedros Adhanom Ghebreyesus. The fund never reached its $100 million potential.
Peter Salama, head of the program, underscored they need a new financing model to sustain the program’s work and capacities. The program can access funding from the U.N. Central Emergency Response Fund and the World Bank’s Pandemic Emergency Financing Facility, but the nature of these two funding platforms are posing limitations for WHO.
“CERF’s lifesaving criteria means that the secretariat is reluctant to fund outbreaks in their early stages until large scale mortality has resulted,” he told member states. “We found this policy counterintuitive and ethically challenging, and we have raised [the issue] several times with the OCHA leadership and the CERF Secretariat.”
WHO meanwhile is a co-chair of the Pandemic Emergency Financing Facility, or PEF, but Salama said the platform is limited to a few groups of viruses and can only be activated once “stringent thresholds” have been reached.
The facility covers six viruses that could likely cause a pandemic, namely Orthomyxoviruses or that causing influenza; Coronaviridae, which was responsible for SARS and MERS; Filoviridae or that causes hemorrhagic fevers like Ebola and Marburg; and several zoonotic diseases, such as the Crimean-Congo hemorrhagic fever, Rift Valley fever, and Lassa fever.
“So it’s not yet actually used, and is unlikely to be needed if we stop outbreaks early as we have done in majority of cases in the past year,” Salama said.
The path forward and a call for investment
The committee recommends WHO to be more proactive in communicating to staff and external stakeholders details of the Health Emergencies Programme, including its structure, functions, and what it is meant to do to address lack of awareness, confusions on authority, and any anxiety arising among staff from lack of information. This includes familiarizing staff with standardized operating procedures, or SOPs, through trainings, focused communications and briefing sessions, although the committee notes that “effective implementation of the SOPs will require a significant cultural shift and fundamental changes in accountability across the organization as a whole.”
The IOAC also suggests WHO strengthen its resource mobilization capacity at country level, and provide support and think of incentives to encourage country representatives to fundraise and engage with in-country donors. Meanwhile, it welcomes news that recruitment for WHO’s resource mobilization unit is ongoing.
On recruitment, the committee encourages the organization to explore flexible contractual arrangements, and adapt contract and roster systems to potentially speed up deployment of needed human resources in emergencies, apart from boosting its HR capacity. A similar roster system can also be applied for partners already vetted by the organization.
WHO can also look into practices by other U.N. agencies on talent acquisition and management, including on the provision of incentives and appropriate rest and recuperation setup for those working in highly stressful environments, to inform its own.
As for addressing procurement issues, the committee suggests WHO to outsource this function, for example with UNICEF, or establish a central division in charge of supply chain management.
While acknowledging outstanding challenges faced by the program, and noting that work is under way to address them, both Tedros and Salama note that the program has accomplished much. In the past year, the program responded to multiple crises, including a number of grade 3 emergencies.
“The program is challenged daily by emerging issues and requests for support,” Salama said, adding that they detect about 5,000 signals of alerts every month.
However, they note that WHO “cannot be limited to responding to every new event.” Investment in prevention and early detection is very important, Tedros said.
“Still, we’re very, very vulnerable. When we visited Madagascar that’s what we’ve seen, though [the plague was] controlled very quickly,” he said. “Of course it shows we can do better from the past, but that cannot cover the vulnerability we have. So we have to know that and that we have more to do.”
The WHO aid chief warned member states that without continued and sustainable funding to help WHO and other organizations to tackle these emergencies and invest in strategies to prevent them from escalating, the world will be “in trouble.” A small investment now could avert the loss of billions later, he said, and reminded member states of the cost of complacency.
“When we panic we give our best, then when things seem OK then we neglect it. Let’s get out of this problem. Otherwise we would again pay dearly,” he said.
Read more Devex coverage on global health.