Post-Ebola: how can the WHO get back its teeth?

The recent Ebola crisis triggered suffering and fear as it crept across borders of countries and even continents. A report on the handling of the epidemic raises a crucial question: can the World Health Organization recover its ability to cope effectively with a global crisis? And if not, who will contain the next epidemic?

Handling an outbreak on this scale is an enormously complex undertaking, requiring cooperation and shared vision on the part of multiple agencies.

When a disease like Ebola crosses borders, depending on local, ad hoc measures is clearly risky.

Yet, if the World Health Organization (WHO) cannot recover its strength, this could be the future of global health care.

In the report “Will Ebola change the game?,” published in The Lancet, Suerie Moon and colleagues from Harvard University in Boston, MA, and the London School of Health and Tropical Medicine in the UK describe the WHO as “an essential hub in the global system for health security,” but they add that it “seems to have lost its way.” Medical News Today recently reported on the overall recommendations of the report.

The authors call for a “more robust, resilient global system able to manage infectious disease outbreaks,” and for a restructuring of the WHO to fulfill that role.

WHO: protecting the world’s well-being

From the 19th century, control of cross-border disease was the first and most widely accepted rationale for intergovernmental health cooperation.

Since the launching of the WHO in 1948, it has helped countries to coordinate multiple organizations, funds, civil society bodies and the private sector to attain health objectives and support national health policies and strategies.

The range of its work is encompassed in its motto: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Since its inception, the organization has enjoyed “near-universal state membership, governance structure and deep relationship with health ministries.”

This has put it in a unique position to perform its four core functions:

• Supporting governments in building capacities for prevention, surveillance and response
• Assessing and providing early rapid response, raising awareness and declaring international public health emergencies
• Establishing technical norms and guidance
• Convening participants to set goals, mobilize resources, resolve conflict and negotiate rules.

Recent successes include reducing child mortality for those under 5, from 12.7 million in 1990 to 5.9 million in 2015; halving the number of people worldwide without access to safe drinking water from 1990-2010; and a 30-47% drop in the number of deaths from malaria from 2000-13.

Decline in effectiveness

Yet the current report criticizes the organization for taking too long to declare the Ebola crisis, withdrawing resources before the crisis was over and for setting up systems that led to blurring of responsibilities.

In the last 20 years, it says, the WHO has lost credibility and confidence, and potentially its ability to respond effectively in future crises.

So what has gone wrong?

For some time, governments and other organizations have been reducing funding, starving the organization of resources. Following the financial crisis, the WHO laid off more than 10% of its headquarters staff, reducing its ability to respond to an outbreak.

While funding has increased from $1.6 billion 1998-99 to $4 billion in 2012-13, changes in funding structure have enabled donors to earmark voluntary contributions, thus eroding the WHO’s control of its own budget to less than 20%.

Moreover, governments and heads of state since the 1990s have increasingly found ways of working around WHO.

Despite successfully controlling nine previous Ebola outbreaks, SARS and other epidemics, over the last 20 years, the WHO has also been losing the credibility, independence and legitimacy needed to carry out its core functions.

When Ebola struck this time, its ability to respond was already reduced.

If the marginalization and decline of the WHO continues, the authors predict that world health will face increasing vulnerability.

In light of the Ebola crisis, how can the WHO regain the strength to cope with future epidemics?

Rebuilding the WHO

The report recommends a number of measures to help the WHO regain their position as defender of the world’s health.

These focus heavily on clarity, determination, surveillance strategies and transparency of information at every level, and a need to work together. They also highlight the importance of support from outside.

We will look at some of the measures and challenges involved.

Investment in core capacities locally

The report calls on the WHO to convene governments and stakeholders within 6 months to begin developing a clear global strategy that will ensure national government investment in building core capacities locally, and to mobilize adequate external support for poorer countries.

It proposes a Global Financing Facility to provide emergency resources, and to fund research and manufacturing of medical supplies, especially when financial incentives are lacking for the private sector. This could also help to ensure equitable provision and distribution of any vaccines and diagnostics produced to all communities, regardless of economic status.

Currently, neither international public financing nor market incentives can be mobilized to fulfill this need.

A 2014 WHO bulletin notes that when the outbreak began, the capacity of the health systems was already limited in Guinea, Liberia and Sierra Leone- the worst-affected countries.

Low-performing essential health-system functions hampered the response to the outbreak. The numbers of qualified health workers, infrastructure, logistics, health information, surveillance, governance and drug supply systems were inadequate, as was the organization and management of health services.

Although external health-related aid has increased in the area in recent years, most has been allocated to combat human immunodeficiency virus (HIV) infection, malaria, tuberculosis and maternal and child health services, leaving little to support overall development of health systems.

The bulletin recommends substantial post-Ebola investment in health systems and reforms in the worst-affected countries to prevent exacerbation of pre-existing deficiencies.

It calls for national governments, assisted by external partners, to develop and implement strategies to develop stronger and more resilient health care systems.

Suerie Moon, lead author of the report, told MNT that there is “significant political momentum” behind these financing efforts for poorer countries, which could mean that such countries are already on the way to being better equipped for the next crisis.

Promoting early reporting of outbreaks

In the words of the report:

“History has shown that early reporting is essential to reduce both the health toll of an outbreak and its political and economic consequences.”

To prevent exacerbation of future crises, the WHO should promote early reporting of outbreaks by commending countries that rapidly and publicly share information, while publishing lists of those that delay reporting.

In the past, the WHO have successfully challenged countries to be more transparent, for example, the Chinese government over SARS.

This time, it took the evacuation of two infected US aid workers, followed by “fear and hysteria” in the US, for the declaration to be made. A public health emergency was finally declared 5 months after Guinea and Liberia had first notified the WHO of the disease.

Factors leading to the delay are reported as opposition from West African leaders, fear of economic ramifications and “a culture within the WHO discouraging open debate about sensitive issues such as emergency declarations.”

Governments are understandably sensitive when it comes to revealing an epidemic, for fear of the panic, economic withdrawal and isolation.

Overcoming this will require a “delicate balancing act between WHO’s role as trusted interlocutor on sensitive outbreak-related information and its role as guardian of the International Health Regulations.”

Countries need to be reassured that cooperating in the interests of global health will benefit them politically in the long term.

Economic incentives could help; nurturing industry relations could encourage private businesses to help ensure continuation of services to emergency areas.

Currently, only the director general has the power to declare an emergency; the report suggests broadening this authority to a politically protected committee, with highly transparent proceedings. The report authors also suggest changing the current yes/no system of declaring an emergency to a graded warning system.

Written by Yvette Brazier