Q&A: The ups and downs of WHO's Health Emergencies Programme

BERLIN — The World Health Organization's Health Emergencies Programme was less than three years old when Dr. Michael Ryan took over earlier this year — putting him in charge of responses ranging from the Ebola outbreak in the Democratic Republic of the Congo to meeting the health needs of Rohingya who had been forced from Myanmar.

The program launched in late 2016 after the West Africa Ebola outbreak revealed WHO's challenges in coordinating a response that cut across its international, regional and country-level programs. It hoped to avoid similar problems in future responses by setting up a program that was able to deploy quickly when emergencies struck, establishing lines of leadership and setting responsibilities. The program is also tasked with helping countries prepare for disasters and to recover after they strike.

Ryan first joined as assistant director-general for emergency preparedness and response in 2017 and described developing the program as akin to rebuilding a subway system while keeping the trains running.

He spoke with Devex at the World Health Summit in Berlin this week about the program's evolution and what he has learned from the challenges encountered in some of its responses.

This conversation has been edited for length and clarity.

What have been some of the program's key developments since you took over?

It's maturing as a program. Being under a lot of operational demands, clearly, that's both pressured the system but also helped us learn more quickly. What doesn't kill you makes you stronger.

The Rohingya crisis has taught us how we operate in a complex, refugee-like situation, with multiple other partners. That crisis is one of the few where we have managed to keep health impacts below that critical, awful level.

We've been under those different stressors — the highly complex conflict situation, the refugee crisis, the disaster-mediated health emergency, and then the infectious disease-mediated health emergency.

We've been cycling through these different events that put different demands on the system, while at the same time having to maintain that upstream [research and development] blueprint for epidemics, pandemic preparedness, influenza preparedness. That stretch from being able to be a credible global policy innovation normative program all the way through to being the last mile.

What we're learning is that we're not strong enough at country level yet. Our country operations, while improving, are not strong enough yet, particularly in these highly complex situations. Our operational model needs further work.

How has that recognition guided the ongoing evolution of the program?

We have really strengthened our regional and sub-regional capacities and we intend to keep doing that — those platforms are so much better aligned to the needs at country level. Better understanding the context. That's been a learning.

The other thing for us at the moment is having a policy for zero growth at HQ and focusing our growth at the regional and country level. It's zero-percent budget increase for the next two years from HQ, but $100 million increase in budgets at the country and regional levels. That's really shifting our focus, pushing more and more the regional platforms to be the response platforms, to be the alert platforms, to be the capacity-strengthening platforms.

What else stands out as a strength of the program?

The Contingency Fund for Emergencies has revolutionized what we do in terms of providing that immediate injection of funds into the system. And that's allowed us to respond to more than 50 events now with immediateness. It's the fastest single contingency fund in the world with respect to responsiveness time.

The downside is we're burning through a lot of money in that and we don't have a sustainable financing method to sustain that.

[With] nearly everything we have a good message and we have a downside. We're in that mid-phase of testing the floorboards and occasionally some of them crack, but we haven't fallen through any of them yet.

WHO has sustained a lot of criticism when it comes to the level of community engagement in the Ebola response in DRC. Do you think it is warranted?

I've been doing Ebola since '96. Nobody understands the anthropological principle and the construct of disease and community response more than our team. We've been in the frontline of hemorrhagic fever response for 25 years. So there's a bit of a misguided thing out there that all of the sudden WHO only woke up to community engagement in the last month.

No one expected the level of community mistrust that we witnessed in North Kivu. And the vast majority of that had nothing to do with Ebola and everything to do with the conflict — and the distrust and the breaches of trust that had occurred for years previously. We just happened to be the latest people in town ...

The scale of that reaction wasn't something we expected. But that wasn't the greatest obstacle. It was difficult to get through and it required us to adjust and take time at times when we felt we had no time. There are very important concepts within community engagement. But there's also an imperative to stop a disease and both have to balance each other out. We have to be very realistic about that. A lot of the problems we had were to do with access and security.

What might you do differently in the future?

We'll be one step cleverer in realizing the situation is more complex. We'll also be working in advance of that with UNICEF and others so that scale-up can happen. We should have been scaling up community engagement all over the province at the beginning ... We should have been looking at getting community engagement going in communities that weren't affected …

The next time we step into Ebola, we're going to be much better served because of the tools we have available. Our capacity to clearly define where we have the at-risk countries and do the advance work, so we're not trying to put in place treatment protocols at two minutes' notice. We get these licenses done at national level. We have pre-agreed treatment protocols, pre-agreed data-sharing agreements.

Is there a tension with the NGO community?

Everyone is constantly trying to set us up against MSF or IRC ... From my perspective, I think [there is a role for] healthy debate, I think we need dissent in the global community. This isn't about achieving an absolute consensus. But what I like to know is: Are we focused on the same thing, are we focused on those vulnerable people? Are we committed to delivering those essential health services they need or whatever we're trying to deliver?

If we have that in mind, then there's no issue. We need a healthy debate. We're a big organization and we're in danger, sometimes, of believing our own bullshit, so we need that constructive external engagement.

I much prefer for us to have a healthy, constructive debate. We can have a debate and then we get on with the issue.

What other lessons do you take from your early days at the helm of the program?

We're really focused on this idea of the national system as the core; really working to strengthen the national capacities, through things like national institutes of health. How do we create a sustainable platform to invest in — we can really leverage that. We can bring in other partners to support that infrastructure. That's a big target. Strengthening our country position and strengthening the country's platform for managing the health security side.