'Business as usual' no longer an option for WHO, member states

The expert panel tasked to review the World Health Organization’s initial response to the Ebola outbreak in West Africa has noted areas in which the organization could have responded better.

WHO, according to the panel’s interim report made public May 11, could have sought support from other U.N. agencies and humanitarian actors that comprise the U.N. Interagency Standing Committee — the body formed in 1992 to help coordinate humanitarian assistance, including in clarifying responsibilities, and helping identify and address gaps in response. The U.N. health agency must have known the limitations of its emergency response capacity and that it needed help to deal with the pandemic.

This might have averted the crisis that later on required the establishment of the U.N. Mission for Ebola Emergency Response, which some critics argue is the result of WHO’s failure to lead efforts to stanch the outbreak.

“At an earlier stage these resources could have been made available and known systems put in place,” the panel argued.

The global health body could also have been the lead authority in crisis communications, with an emergency media team put in place to manage WHO’s messaging and content. A robust communication strategy might have helped counter the “very critical reporting” on WHO’s work, which was compounded by what many argue is a “delayed declaration” of the crisis being a public health emergency of international concern, as well as by “misleading Twitter messages and leaked documents.”

A Twitter exchange between a WHO spokesman and Médecins Sans Frontières, which has been the U.N. health agency’s most vocal critic, reportedly took place in the initial phase of the epidemic over the latter’s calling of the outbreak “unprecedented.” The Associated Press meanwhile reported on internal email exchanges within WHO that had an impact on the organization’s decision on when to announce the crisis as a public health emergency of international concern.

A leaked document also revealed internal issues that relate to WHO’s communication and structure; it showed how disconnected or unaware Geneva was from what’s going on in West Africa.

The panel said “it is still unclear why WHO was not able to engage in a high-level media response with greater command over the narrative.”

They are also “surprised” that it took until later in the crisis before the actors responding to the outbreak recognized that surveillance, community mobilization and appropriate health care delivery to Ebola-affected communities were key in bringing the outbreak under control, when WHO has “extensive experience with outbreaks, health promotion and social mobilization.”

And it is “still unclear” to them why early warnings — those before August when the crisis was announced as an international public health concern — did not immediately result in an “effective and adequate response.”

The panel says they are still exploring reasons for this delay, including looking at the political, cultural, organizational and financial factors.

IHR’s weaknesses

The panel does however recognize that much of the gaps and limitations, or the unintended consequences relating to WHO’s response, has to do with its very own structure, and underscored the importance of organizational alignment across the three levels of the organization, the director-general taking leadership, and the strengthening of its own International Health Regulations.

On the IHR, for instance, the panel has requested the review committee to examine member states’ responsibilities in notifying the organization of public health threats and in abiding by IHR regulations, and suggests the consideration of “indemnification options” for those who fail to follow on these responsibilities. It also suggests introducing sanctions to countries that implement measures beyond IHR recommendations.

Despite the absence of recommendations from the IHR review panel, several countries closed their borders and restricted travel, especially of those coming from Ebola-affected countries, in the early phase of the response. This had a huge impact not only on the affected countries’ economy, but also in the aid response, as it lengthened the time for personnel and supplies to reach countries in need.

“While the panel recognizes that each member state is a sovereign country with as its first priority the health of its own citizens, in our globalized world, where the health of one state is so interconnected with that of others, governments nevertheless also have a responsibility to act as global citizens,” it argued.

The review committee should also consider different levels of alerts in health emergencies, allowing for early international engagement. At present, there’s only one alert under IHR — the public health emergency of international concern — that requires immediate international action.

WHO, meanwhile, should come up with a plan — properly funded by donors, member states and other stakeholders, or through new types of financing mechanisms — to independently evaluate member states’ core surveillance and response capacities in health emergencies, which is a requirement under IHR. At present, member states’ capacities are evaluated based on their own self-assessments, while some do not communicate their status or intentions of building these capacities at all.

WHO’s operational capacity

WHO’s publicly perceived poor performance has led critics to call for the establishment of a new agency in charge of health emergencies, or for WHO to relinquish the responsibility to another organization.

The panel acknowledges that there is a “strong, if not complete, consensus that WHO does not have a robust emergency operations capacity or culture.”

But it insists the international community’s time and resources would be better used on efforts to strengthen WHO’s operational capacity in emergency response. A different organization would still require coordination with WHO for technical input and guidance, and setting up a new agency would be more resource intensive.

“The panel puts this recommendation to the Health Assembly now so that the overarching strategic direction is clear and that change can be driven forward quickly,” the panel said, noting that if member states agree, the implementation of the proposed contingency fund and the global health emergency workforce can immediately move ahead and be in place before the next public health emergency.

But additional resources aren’t enough to strengthen WHO’s capacity to respond to health emergencies. The panel argues all WHO staff should also have proper understanding of what emergency response requires, and those likely to be deployed be given thorough training, including simulation exercises.

WHO should also address its own skills gap on crisis coordination and leadership, which are of particular importance in large-scale emergencies like Ebola. The panel was however quick to note that in country coordination should be led by affected countries’ governments themselves, “where possible.”

Not everything needs to be built from scratch. For instance, on logistics, WHO could explore partnerships with other actors with known logistical capacities, as it did with the World Food Program early this year. These relationships should however be developed as part of preparedness measures, and not when a crisis is already in place, the panel emphasized.

Member states’ responsibilities

WHO’s member states play a big role in the organization’s work and function, and that’s why the panel also recommends actions member states should take in support of building a stronger global health agency.

When an emergency as big as Ebola occurs, for instance, member states should be flexible enough and recognize that some of the organization’s work “may be delayed or postponed.”

They should also be ready to increase their core contributions to the organization, especially now that it is working on a structure for more robust emergency response.

At present, member states’ assessed contributions account for only 25 percent of the organization’s biennial program; the rest comes from voluntary contributions, the bulk of which are earmarked for specific purposes. And according to the panel, the WHO Secretariat’s resources that would allow it to monitor the implementation of the IHR and provide necessary technical support have been “reduced to a level the panel believes is now inadequate.”

“Each global health crisis has shown the tragic consequences … of the failure of countries to invest in global public goods for health. Those weaknesses are then mirrored as weaknesses in WHO, as the organization suffers from a lack of political and financial commitment by its member states despite the global health risks they face,” the panel said.

As for the proposed contingency fund, the panel recommends this be developed with the idea that it be used to prevent crises, instead of simply for response purposes. It hopes it would have these four elements: flexible, transparent, aligned with needs on the ground, and predictable; and that the director-general be given discretion to use some of the funding for payments to countries for staffing, including for hazard pay, insurance and evacuation of health care workers.

Remaining questions

The panel acknowledges this is a “defining moment” for WHO’s work.

“‘Business as usual’ or ‘more of the same’ is not an option,” the panel argues, and the WHO Secretariat needs to take these steps to “earn this leadership role” in outbreaks and emergencies, and to “regain the trust of the international community.”

But the report is not yet full, and the panel expects to complete its assessment in late June or early July, following planned visits to the Ebola-affected countries and WHO’s regional office in Africa, as well as discussions with other actors involved in the response.

Some of the questions that it hopes to address by then is when and if the broader U.N. system needs to be brought together in an emergency situation. While it recognizes WHO is the health cluster lead in major humanitarian crises, it is unclear to the panel “how a public health emergency fits into the wider humanitarian system and at what point an outbreak becomes a humanitarian emergency that requires a broader U.N.-wide response which would include coordination with the many nongovernmental organization actors on the ground.”

It would also explore whether a UNMEER type of response would be the appropriate model in managing future large-scale health emergencies

As for the structure WHO is currently developing to boost its emergency response capacity, the panel said it would be “pleased to review it” and recommends it be put in place “as quickly as possible” and work reported to the executive board in 2016.

The panel suggests the organization merge its outbreak and humanitarian or emergency response activities to create a “single, unified entity within WHO for emergency response.”

What other changes should WHO and its member states implement to strengthen the U.N. health agency’s emergency response capacity? Have your say below.

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