JAMA Forum: Critical Choices for the WHO After the Ebola Epidemic

BY LAWRENCE GOSTIN, JD on MAY 27, 2015

Lawrence Gostin, JD (Image: Georgetown University Law Center)

In the aftermath of an unconscionably inadequate response to the Ebola epidemic in West Africa, this year’s World Health Assembly was seen as critically important to the future of the World Health Organization (WHO). The assembly, the WHO’s decision-making forum, attended by delegations from all WHO member states, offered a historic opportunity for fundamental reform of the organization. A failure to decisively shore up its epidemic response leadership risked the loss of confidence in the WHO for a generation.

When the 68th World Health Assembly convened on May 18, 2015, the WHO was experiencing a crisis of confidence. The assembly took 3 key steps to address the organization’s global health security capacities: it combined the secretariat’s outbreak and emergency response programs, developed a new global health emergency workforce, and created a $100 million emergency contingency fund. What the assembly did not do was address the deep structural problems that have plagued the WHO, undermining its effectiveness.

Integrating Outbreak and Emergency Response

Margaret Chan, MD, DSc, director-general of the WHO, announced during the assembly that she plans to combine the existing outbreak and emergency response programs into a single program for health emergencies. This new unit will be designed for speed and flexibility, she said, with program performance benchmarks “showing what must happen within 24, 48, and 72 hours, not months.” The program will partner with United Nations agencies, states, and nongovernmental organizations (NGOs), such as Médecins Sans Frontières (MSF).

From an organizational perspective, the new unit will be more rational and designed for rapid response. Yet, there are no new funding sources to support outbreak and emergency response. If Chan diverts significant resources to its epidemic response, she risks further weakening already badly underfunded programs, such as for noncommunicable diseases and mental health.

A Global Health Emergency Workforce

The absence of a robust domestic workforce represented a signal failure of the West African Ebola response. The 3 most-affected countries—Guinea, Liberia, and Sierra Leone—had among the world’s lowest health worker-to-patient ratios, and lost more than 500 doctors, nurses, and other health workers to the epidemic. Although NGOs such as MSF and foreign workers filled some of the gap, the paucity of human resources significantly impeded the response.

Although the WHO is doing very little to build human resource capacities in low- and middle-income countries, Chan announced in a report to the assembly that the agency does plan to launch a global health emergency workforce by January 2016, drawn from existing networks including the Global Outbreak Alert and Response Network (GOARN), theGlobal Health Cluster, foreign medical teams, and NGOs, and coordinated by the new outbreak and emergency response unit. Chan also announced that the WHO is strengthening its own emergency staff, adding logisticians, medical anthropologists, and experts in risk communication. The assembly welcomed both of Director-General Chan’s proposals to establish for a global health workforce and to strengthen the WHO’s emergency response unit.

The Ebola response vividly demonstrated that effective action requires a range of human resources, including clinicians and community health workers, as well as public health professionals to conduct surveillance, laboratory analysis, and contact tracing. Other experts in communications, culture, and behavior are needed to gain insight into local belief systems. These skills should be ensured through comprehensive training and certification, which will be crucial WHO functions.

Although a global workforce reserve requires intensive training, medical equipment, and logistical acumen, the WHO is implementing the emergency workforce without any new resources. It is hard to conceive how such a vital operation can be conducted without a major injection of sustainable resources.

A $100 Million Emergency Contingency Fund

In 2011, after the influenza A(H1N1) pandemic, the independent WHO International Health Regulations (IHR) Review Committee found that the world is “ill-prepared” for a major epidemic and proposed a $100 million contingency fund. But the WHO never adopted the committee’s recommendation. Chan’s strategy was to mobilize international funding when an emergency strikes, believing that rich states and philanthropists would react quickly to exigent circumstances.

However, as the WHO should have realized, once a rapidly moving infectious disease emerges, it may be too late to first begin resource mobilization. That turned out to be the case with Ebola, as the WHO’s funding appeals took too long to materialize. During the World Health Assembly, delegates approved the creation of a $100 million contingency fund, financed by flexible voluntary contributions.

Director-General Chan was heavily criticized for delays in declaring a Public Health Emergency of International Concern (PHEIC) under the IHR. Wisely, release of the contingency fund will not be tied to a PHEIC declaration. After a WHO committee discussed the more flexible approach of using the principles of the Emergency Response Framework grading system as the trigger for tapping the contingency fund, the assembly ultimately left the decision to release funds at the director-general’s discretion.

The clear goal of a WHO contingency fund should be to prevent an event from escalating into a PHEIC or an even lesser–grade emergency. Yet at $100 million, the fund’s size is incommensurate with the need when one considers the billions of dollars in humanitarian assistance and the loss of approximately 12% of the GDP in the countries most affected by the epidemic. It also requires voluntary contributions from member states or other donors. Adding it to WHO core funding through mandatory assessed dues would have been more viable and sustainable.

Deeper Structural Reforms Are Needed

None of 5 proposals for structural reform of the WHO that I suggested in a previous JAMA Forum were on the assembly agenda in a meaningful form. In particular, member states did not significantly increase the assessed dues of WHO member states to give the agency the funding and control it needs to meet its worldwide mandate. The lack of coherence between headquarters and its regional offices remains unaddressed. And although the secretariat is exploring new ways to harness the creativity of civil society and avoid conflicts with vested business interests, there was nothing on the assembly agenda to bring NGOs closer into the WHO’s governance.

Finally, and most importantly, the WHO has not developed a plan to build the core capacities of low- and middle-income countries for sustainable health systems. The idea of an international health systems fund to accomplish this was not on the agenda.

The WHO is too important to be sidelined or weakened further, but the organization’s ability to provide meaningful leadership is not assured. To be sure, the WHO has improved its ability to put out fires in the form of rapidly emerging infectious diseases. Although there is a better fire brigade, the assembly has yet to take action to prevent fires from erupting with increasing frequency in every region of the globe.

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About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.