Inside WHO's reform agenda

The past few months has seen the embattled World Health Organization embark on a sea change. Dr. Bruce Aylward, who heads the organization’s polio eradication and humanitarian response, replaced Dr. Keiji Fukuda as the organization’s lead in the Ebola response. New faces were placed at the organization’s country offices in the three countries most-affected by Ebola. And at the 136th session of the organization’s executive committee in January, the beleaguered head of WHO’s regional office in Congo, Dr. Luis Sambo, stepped down and was formally replaced by Dr. Matshidiso Moeti from Botswana. But those comprise just a small part of the wide-ranging reforms being implemented at the world’s premier health agency, whose response to the Ebola outbreak in West Africa has put its capacity, reputation and relevance to the test. Lessons learned Some of the reforms the organization has taken and plans to take are based on its own experience in dealing with the crisis. Others were borne out of scathing assessments of its leadership, which led the organization to recognize the need to implement changes in its systems and boost its capacity in emergencies. In a joint leadership statement released to the public a couple of weeks ago, the organization spoke of lessons learned from the epidemic — of humility, fragility, importance of capacity, understanding community and culture, solidarity, coordination and communication. It pledged to change the way it is currently working, recognizing the need to take a “command and control approach” in disease outbreaks as opposed to a “consensus building culture” that it applied to most of its global public health work — perhaps in response to criticism over its missing leadership role in the early phase of the Ebola outbreak, although the latter part has been removed and several points have been altered in a “corrected” version. It also promised to strengthen the International Health Regulations framework, ensuring countries develop their capacities to respond to health threats, such as Ebola, and establish a mechanism to be able to independently verify national capacities. And it committed to establish partnerships with different organizations, as it already did with the World Food Program. But some of the implemented reforms were part of member states’ request in January, such as the launch of the organization’s own registration system that would allow it to mobilize medical experts from around the world immediately in the event of a humanitarian emergency or outbreak. Another is the organization’s pledge to expand its core staff working on diseases with outbreak potential and health emergencies, and create another surge capacity of reserve workforce of trained and certified staff. And in order to do this, the organization is expected to apply changes in its human resource strategy and policies. In practice, that means additional resources will be allotted to the organization’s human resources, so it would be able to manage and coordinate the work of WHO in crisis situations, according to Aylward. The organization will also be looking at its own HR systems, and see where changes can be implemented in the identification, recruitment and retention of staff so that it can be “much faster, much more efficient” in mobilizing them in times of crises. All these, he argued, are in response to the widely recognized problem of undercapacity within the organization. “These are all part of a recognition that emergency operations need to be a much bigger aspect of the overall work that the organization does, rather than the relevancy of the limited role it currently plays in the overall work of the organization right now,” he told Devex from Conakry, Guinea. The 3 aspects of the HR reform In moving ahead with reforms on human resources, however, Aylward notes the importance of first looking at three critical aspects of the organization. The first is to make sure there’s structural alignment across the three levels of the organization. That means everyone across the organization is clear on the organization’s decision-making processes, its strategy and budgeting, as well as have a common approach to managing different kinds of hazards. “We can’t manage the infectious outbreaks one way, and then humanitarian emergencies the other way,” Aylward said. Second, assess the efficiency of the organization’s systems to see whether it can quickly move money across budgetary lines, for example, or effectively mobilize people from its different offices worldwide. Third, evaluate the organization’s current capacity and identify areas that can be boosted. This includes logistics and operations, making sure the organization has capacity to support its field missions. No clinical care That said, Aylward stressed the organization’s role in emergencies will remain focused on coordination, information sharing and planning, and providing technical advice. It will still not be involved in actual, direct clinical care. “That is not usually what the organization does, and we will continue to be what we call a provider of last resort in that regard,” he pointed out. That means the organization will continue to rely on foreign medical teams, the Global Outbreak Alert and Response Network, and its health cluster partners to play those specific roles. Discussions on how appointments are made across the organization will form part of the process as well, including how staff will be evaluated over time for their work. One of the biggest criticisms hurled at the organization is harboring “incompetent people” within, as a result of appointments being done on a political basis rather than based on real competencies. Daniel Epstein, WHO’s spokesman in Washington, D.C., said he doesn’t think the organization has so much of those “incompetent people that needs to be fired.” In the case of Ebola, however, he acknowledged that Director-General Margaret Chan moved people who have more experience in emergency response to positions of authority. Dr. Anders Nordstrom, who served as acting director-general before Chan’s appointment, was made the new head of WHO’s office in Sierra Leone, for example. A more robust communication strategy Member states have also requested Chan to develop and implement a communications strategy across WHO that would “improve routine communications, messaging about preventive measures, risk communication and emergency communications.” It’s unclear how much of this has been implemented, but Aylward said that when it comes to emergency situations, communication across the three levels of the organization has become “more formalized, much bigger.” If before WHO conducts daily “shock meetings,” today it now has daily scheduled teleconferences, which regional and country offices can dial into, that looks into the virus’ latest epidemiology. These calls would have detailed reviews right down to district-level operations to ensure everyone across the organization are on the same page on how the epidemiology is evolving and how the response is adapted to account for these changes. In addition, weekly calls are set up with country offices to go through their specific issues and needs. And every two to three months, they do face-to-face meetings with all country teams to ensure the whole-of-organization response is aligned at the strategic, technical, administrative and operational level. It’s not certain whether the current system will be implemented in future emergencies WHO will be involved in. The general understanding is that a new system is being looked at to ensure alignment across the organization. Regardless, this communications strategy for emergencies is a clear response to the coordination challenges the organization faced in the initial stages of its Ebola response. In reports, Chan admitted to only learning of the breadth and scale of the virus much later, when WHO was already being heavily criticized for its seemingly slow and inadequate response. What else to expect In the coming weeks and months, WHO is expected to establish a contingency fund that would allow the organization to quickly mobilize financing in an emergency. This was previously proposed by the International Health Regulations committee in 2011, but failed to materialize. Today though, it might be closer to being realized. That’s because the recommendation now comes from member states themselves, according to Aylward, and not just from a review committee. “That’s going to carry much more potential support than something from a review committee,” he said. “And obviously, we’re operating in a different time now, where there’s much more recognition of the need for this.” Chan is expected to put forward a paper containing proposals on the size, scope and operational function of the fund at the upcoming 68th World Health Assembly. But WHO’s leadership is not just relying on the contingency fund. Chan is also expected to ask member states for a “very specific budget increase” to strengthen the organization’s core emergency operations. It’s unclear at this stage where Chan hopes to mount that increase, whether from member states’ assessed contributions or from the organization’s voluntary contributions; the latter covers the bulk of the organization’s budget. Discussion are still in the very early stages, Aylward noted. But there’s no doubt WHO’s much-criticized Ebola response and the resulting reforms will be front and center at the event in May. Check out more insights and analysis for global development leaders like you, and sign up as an Executive Member to receive the information you need for your organization to thrive.