Reforms are needed if the WHO is to be able to continue to respond to major crises.
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 WHO was created to take care of global health.
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.
- WHO figures show that total health spending per person per year on health in the US is $8,362
- In Eritrea, total spending per person per year on health is $12
- The WHO say that a minimum of $44 is needed to provide basic, life-saving services.
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.
Countries hit by Ebola were already depleted in health care resources.
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.
Deciding when to declare a crisis can be a difficult decision.
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.
Establishing a dedicated outbreak response center
National governments are responsible for health care in their own borders, but the WHO is "crucial as the second line of defense when governments need international support or when an outbreak strikes in more than one country."
A strong WHO is needed to ensure global protection from future outbreaks.
The report calls for a Global Health Committee at the United Nations Security Council (UNSC), which Moon says "can be implemented quickly."
It also recommends a dedicated outbreak response center within the WHO, with strong technical and analytical processing capacity, a protected budget and clear lines of accountability and authority, governed by a separate board.
Moon told MNT that while this will require political leadership, it will cost little and can be implemented quickly.
Capabilities of existing outbreak response would be merged with those of the WHO's humanitarian teams, and tasks would include developing protocols, building relationships, negotiating agreements with all parties and ensuring government-to-government communication through rapid information-sharing channels.
Reviewing the WHO's core focus
The authors suggest scaling back the WHO's wider range of activities to focus on its four core functions, specifics of which should be redefined by the Executive Board.
Non-core activities should be handed over to other bodies. This would free the WHO to decide which funding to accept, enabling more focused decisions about funding, which could lead to more non-earmarked voluntary contributions. Thus, the WHO could regain control over its spending.
Sharing of research and information
Successes during this crisis include the convening of experts on research and development, guidance, norms and regulatory approval, and setting up clinical drug trials in record time.
Outstanding scientific progress was made during the crisis, but long-term strategies and data sharing need improvement.
Gijs Van Gassen, of Medicins Sans Frontieres (MSF), which collaborated with the WHO on development of the VSV vaccine, told MNT that intermediary results of the VSV trials are now being analyzed and final conclusions being prepared.
However, as Moon told MNT, transparency, information-sharing and accountability are a central theme of the report, as they were key weaknesses during the outbreak.
Lack of communication led to fragmentation and duplication of tasks and data. Moon calls for stronger arrangements to ensure real-time data sharing by responders during future outbreaks.
Data-sharing could also help counter competition between researchers during an emergency. Commitment to sharing could be a prerequisite for research funding from the new Global Financing Facility.
The report stresses the need for "an overarching framework to give coherence and fill gaps in the fragmented system of international rules shaping outbreak-related research."
Regaining confidence, trust and respect through reforms
The authors call for "a new deal for a more focused, appropriately financed WHO."
They recommend that governments should finance most of the budget with untied funds, leaving the WHO free to focus on its task as global health caretaker.
In exchange, the WHO needs human resources management reform and a director general "with the power and the capacity to challenge even the most powerful governments when necessary to protect public health."
Unproductive staff should be let go and a freedom of information policy introduced.
As Moon told MNT, more transparency from the WHO would help rebuild public confidence, and the freedom of information policy would "underscore the principle that WHO is a publicly accountable agency."
Change needed at all levels
How will the world face future epidemics if the WHO loses its power? Can the reforms be made to work?
The report stresses the urgent need for reform and for strong commitment from all sides, including heads of state, to ensure security for communities, both global and local.
- 11,314 people died of Ebola in the recent epidemic
- There were 28,634 cases of the disease
- In the US, there were four cases and one fatality.
Bulletins released during the outbreak describe some of the challenges faced on the ground, emphasizing the need for change to trickle down to local communities.
The report refers to the "many acts of courage, solidarity, innovation and leadership" displayed during the crisis, often at great personal loss, including more than 800 local caregivers that contracted the disease, of whom 500 died.
The WHO stated in December 2014 that with health care facilities in affected areas focusing fully on Ebola, people with other conditions were being turned away, including those with fevers that were not Ebola-related. They then sought care for non-Ebola conditions in supposed Ebola-free areas, putting strain on the health system there. The WHO concluded that regular health care must be maintained during emergencies to avoid worsening the situation.
In July 2015, MSF noted that communities remained fearful and reticent about recognizing the disease or seeking care in specialized centers. Even as the epidemic receded, cases remained undetected, with 25% of positive cases still not identified until after death.
MSF highlight the need to involve local communities, to gain trust and confidence and help allay the rumors and myths surrounding Ebola. Community-centered solutions are essential in this kind of crisis: a one-size-fits-all approach does not work when communities are so diverse.
Moon believes that the impact of some of the reforms on local communities will be immediate and clear. Strengthening the WHO's technical, financial and organizational capacity as a rapid responder will improve support for outbreak control efforts.
Provision of drugs and vaccines will take longer, as it first requires barriers to be broken down from the top.
The report authors conclude that "Ebola developed from a relatively small outbreak into a large-scale emergency because of the failures of multiple actors to fulfill their mandated roles and responsibilities," resulting in huge loss of life and a weight of human suffering that will persist for decades.
The WHO comes under fire in the report, but this is a burden for the whole world to bear.As Moon told MNT:
"The key aims of the report are to convince policymakers to act now to reform the system so that we are better prepared for the next outbreak, and so that the tragedy of the Ebola epidemic is never repeated. This will require actions taken by all governments, and by officials of the World Health Organization, United Nations, and others."
Without cooperation and support on every level, global health security cannot be assured.