By Maxine Builder, research associate, and Laurie Garrett, senior fellow for global health at the Council on Foreign Relations in New York.
World Health Organization Director-General Margaret Chan began her address to the 66th session of the World Health Assembly on Monday on a grim note, reminding WHO’s legislative body of the 2003 SARS epidemic, which spread to 37 countries, leaving 8,273 sick and 775 dead. Chan then compared that outbreak to two new diseases: a novel coronavirus from the Middle East, and the H7N9 avian influenza virus.
She continued: “These two diseases remind us that the threat from emerging and epidemic-prone diseases is ever-present … A threat in one region can quickly become a threat to all.”
But the threat of a global pandemic is not the only challenge WHO is facing now. The organization is also suffering from deep budget cuts, and is reassessing its role within the framework of global health. If one thing is clear from these first few days of the World Health Assembly, it is that the WHO of tomorrow will not be the same hegemonic health powerhouse of the past. It will likely be more decentralized, placing a greater share of the responsibility for health on individual nations. Countries will be compelled to carry the onus for provision of health, including epidemic control, on their own shoulders, increasingly based on domestic revenues.
But WHO still has an important role to play in providing technical support, especially in times of crisis. Below are three recommendations for how the organization can adapt to an uncertain economic and political environment, without putting the world at risk of a disease outbreak.
1. Fully implement the 2005 International Health Regulations
This legally binding agreement, signed by 194 nations in 2007, creates a global framework for responding to “acute health risks that have the potential to cross borders and threaten people worldwide.” All countries were expected to meet a set of laboratory, surveillance and response guidelines by 2012, but 117 nations formally requested more time. Only 13 of the 194 fully met all of the criteria by the deadline.
A strong reporting system can be successful in calming the spread of disease. For example, China has been praised for its response to H7N9, especially in comparison to its response (or initial lack thereof) to SARS 10 years ago. This time around, China quickly reported the outbreak to WHO’s Global Alert and Response mechanism, created under the IHR. WHO was then able to respond with a team of investigators to study the spread of this avian flu. Additionally, Chan said that the improvements the Chinese government made to upgrade capacity after SARS helped the country efficiently manage this outbreak. Although she and others admit that we still do not know the full spread of the disease, the fact that no human cases of H7N9 have been reported since May 8 is an encouraging sign that this response mechanism has — so far — been successful in mitigating the spread of H7N9.
WHO therefore deserves credit for the 31.7 percent increase in its budget for preparedness, surveillance, and response, of which about $287 million would be deployed to countries in training and development of systems, necessary to abide by the IHR. The recently released strategic framework from Chan’s office cites “ensuring that all countries can meet the capacity requirements specified in the IHR” as a leadership priority for 2014-19. It is crucial for WHO to follow through fully on this implementation, but the success of this architecture is also dependent on WHO’s own capability to respond. This brings us to the second recommendation.
2. Keep a strong institutional safety net for outbreaks of communicable disease
The IHR are only as strong as WHO’s ability to respond to surveillance reports, especially in times of crisis. Part of WHO’s mission is to “provide technical assistance and, in emergencies, aid,” and the organization needs to ensure provision of a safety net in the event that preventative measures fail. The H7N9 outbreak in China, and the recent spread of a novel coronavirus throughout the Middle East, the United Kingdom and France demonstrate the continued need for WHO to facilitate global responses to outbreaks. The dramatic 51.4 percent decrease in the budget for crisis response therefore seems premature. WHO should not slash funding from this segment of the budget, and funding cuts to acute responses should not be considered until all member nations have met the requirements of the IHR. Even though WHO faces increasing budgetary limitations, its support system must remain strong as countries turn to WHO for expert advice in the face of disease outbreaks.
3. Find sustainable funding sources and close the wealth gap
If WHO is going to shift more responsibility in terms of disease surveillance and response to individual nations, there must be sustainable funding mechanisms in place for these countries to tap into. There has already been a shift away from nations that are dependent on donations from outsiders to cover the financing of their healthcare and preventions programs, and WHO should encourage more domestic financing of these systems, and mechanisms such as tough taxation of alcohol and tobacco products.
Country revenues to finance public goods, including medical and public health services, cannot be sustainably covered, however, with modest sin taxes. Since 2008 vast reserves of wealth have disappeared from the global economy, with an estimated $27 trillion to $32 trillion hidden in various havens, unavailable for taxation. The loss of vital domestic revenues is especially acute in countries reliant on extraction industries, such as petroleum, minerals and gems. Enforcing transparency and taxation will both confront corruption and reap a long term harvest of national revenues.
In the post-2008 financial environment, most regions of the world have witnessed a marked widening in the gap between the relative wealth of the top 1 percent of their societies, and the remainder of the populations. Save the Children found that “in Nigeria the poorest children are more than twice as likely to die before their fifth birthday as the richest children.” WHO recognized in its strategic framework the importance of “addressing the social, economic and environment determinants of health” as a way to reduce health inequalities. This is clearly not a problem that WHO can solve on its own, but it is heartening to see that it is part of the discussion. A key first step toward minimizing the impact of wealth disparity on health lies in provision of affordable universal health coverage. As delineated in a CFR/Dalberg report on this, health costs rank among the top two causes of family bankruptcy in most countries, representing a leading cause of impoverishment.
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