The Future of the WHO: Lessons Learned and Priorities for Reform

Transcription

1 insights from a cfr workshop The Future of the WHO: Lessons Learned and Priorities for Reform February 9, 2016 In November 2015, the Council on Foreign Relations (CFR) International Institutions and Global Governance program held a workshop on the lessons learned from the World Health Organization s (WHO) response to the Ebola outbreak in West Africa and prospects for WHO institutional reform. The workshop was made possible by the support of the Robina Foundation. The views described here are those of workshop participants only and are not CFR or Robina Foundation positions. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government. In addition, the suggested policy prescriptions are the views of individual participants and do not necessarily represent a consensus of the attending members.

2 1 CONFERENCE TAKEAWAYS The Ebola outbreak in West Africa laid bare the deficiencies of the World Health Organization (WHO) by casting doubt on the organization s capacity for outbreak surveillance and emergency response, as well as the organization s relevance in an increasingly crowded and fragmented global health landscape. Despite its shortcomings, however, the WHO remains vital to global health governance and is uniquely positioned to coordinate responses to future international public health emergencies. Given the growing number of competitors, the WHO should make better use of its limited resources, narrow its agenda, and scale up its work in those areas where it has a comparative advantage, particularly the management of infectious disease outbreaks. However, the WHO also needs to promote accountability, separate public health emergencies from competing political interests, demonstrate decisive leadership, and reinvigorate relationships with member states, nongovernmental organizations (NGOs), and the private sector. The fragility of the West African states hit hardest by Ebola Guinea, Liberia, and Sierra Leone demonstrates that impoverished countries with weak public health systems are illequipped to prevent, detect, and respond to infectious disease outbreaks. The WHO should redouble efforts to implement and enforce compliance with the International Health Regulations (IHR) in these vulnerable states, and collaborate with partners particularly in the private sector to spur investment in public health capacity. INTRODUCTION Since it erupted in West Africa in December 2013, the worst Ebola epidemic in history has claimed more than eleven thousand lives in six countries around the world. Nearly all of these fatalities were in Guinea, Liberia, and Sierra Leone, where weak public health systems, poor infrastructure, distrust of government and foreign aid workers, and porous borders enabled the outbreak. Despite warnings from NGOs in the field, the World Health Organization failed to recognize the gravity of the situation until August 2014, by which time the epidemic had caused nearly one thousand deaths and spread to Nigeria, Africa s most populous country. Political calculations, a culture of impunity, competing incentives, budget cuts, and a dearth of qualified personnel all impeded a robust WHO response. Although the outbreak was under control by the end of 2015, the Ebola crisis threw into sharp relief the shifting landscape of global health governance and the precarious state of the WHO. On November 2, 2015, the International Institutions and Global Governance program at the Council on Foreign Relations convened experts and practitioners from academia, government, NGOs, and the private sector to assess the WHO s performance during the Ebola epidemic, to identify its comparative advantages amid a fragmenting global health landscape, and to discuss prospects for institutional reform in light of lessons learned. EBOLA REVEALS GAPS IN GLOBAL HEALTH GOVERNANCE The World Health Organization s lethargic response to the Ebola outbreak revealed systemic weaknesses and gaps in health emergency preparedness and response. In explaining the WHO s

3 2 belated recognition of the severity of the epidemic, participants highlighted the multiple failings of the International Health Regulations, the legal regime undergirding management of cross-border infectious disease threats. First instituted nearly fifty years ago and revised in 2005 in the wake of the severe acute respiratory syndrome (SARS) pandemic, the IHR require all countries to establish minimum core capacities to prevent, detect, and respond to infectious disease outbreaks; to immediately notify the WHO of potential public health emergencies of international concern (PHEICs) within their territories; and to abide by the WHO s technical recommendations regarding travel and trade restrictions on outbreak-affected countries when PHEICs do occur. During the Ebola crisis, however, the IHR broke down on each of these fronts. West African political leaders and WHO officials downplayed the outbreak, dismissing increasingly dire warnings from Médecins Sans Frontières (MSF), also known as Doctors Without Borders, as alarmist, according to one workshop participant. This tendency to downplay emergencies is symptomatic of a larger problem: political leaders are reluctant to alert the world to looming public health crises out of concern for political and economic stability; the WHO, loath to defy its member states, often follows suit. In the case of Ebola, such fears were borne out. In the panic of the crisis, numerous countries imposed unnecessary border closures, an economic blockade, and flight suspensions on Ebola-affected countries, contrary to their legal obligations under the IHR to maintain open travel and trade. Participants emphasized that these restrictions not only disrupted the flow of foreign health and aid workers to and from the region, but also wrought economic hardship on Ebola-affected countries. The example of Ebola could discourage states dealing with a potential health emergency from alerting the WHO, as required by the IHR. The epidemic also reflected the failure of the WHO to facilitate implementation of the IHR capacity requirements. As of November 2014 more than two years after the original deadline of June 2012 only sixty-four countries had achieved the required core capacities. At present, countries assess their own progress, but given the fragility of developing countries public health infrastructure, participants noted that self-assessment is insufficient. They argued that more rigorous, independent methods of monitoring progress such as third-party evaluation should be explored. Workshop participants emphasized that the WHO s bungled response to the Ebola crisis was not without precedent. Similar lessons had been learned from the 2009 H1N1 influenza pandemic. In 2011, an independent review of the response to that In the panic of the crisis, Ebolaaffected countries were subjected to unnecessary border closures and an economic blockade. outbreak found that the world remained ill-prepared for future health emergencies, that the WHO lacked the internal capacity for sustained response to PHEICs, and that many developing countries were not on track to meet the minimum standards set by the IHR. As a first step toward remedying these shortcomings, it was recommended that the WHO establish a reserve of emergency health workers, create a $100 million contingency fund to support surge capacity in the event of a PHEIC, and accelerate implementation of the IHR in developing countries. However, the WHO and member states failed to heed these warnings and subsequently took measures that undermined the organization s capacity to manage infectious disease outbreaks. Under pressure to address an ever-expanding array of global health challenges with limited resources, the WHO

4 3 slashed budgets and personnel dedicated to outbreak surveillance and emergency response. Participants stressed that if the WHO had acted on these recommendations in 2011, countless lives might have been saved during the Ebola outbreak. Participants also underscored the importance of understanding local conditions and communities. The WHO s failure to contain the outbreak, said one participant, stemmed from its ignorance of local circumstances. Rather than tailor a response to the unique sociopolitical and cultural context of the hardest-hit West African countries, the WHO adopted a one-size-fits-all approach that was bound to fall short. The virus emerged in a small village in the forests of Guinea near its porous borders with Liberia and Sierra Leone. In the minds of locals, said one participant, there are no borders; an outbreak in one country inevitably spread to all three because of the cultural and familial ties among communities straddling these borders. Making matters worse, local populations and health workers were unaware of precautions that could disrupt transmission because Ebola was previously unknown in this part of Africa. Foreign aid workers and government officials already distrusted after years of civil strife failed to clearly communicate the risks of Ebola, which exacerbated hostilities. In the words of one participant, Ebola is a disease of human choices and behavior. THE WHO IN A SHIFTING GLOBAL HEALTH LANDSCAPE The tragic Ebola outbreak took place against the backdrop of a historic transformation in global health governance. Unlike in 1948, when the WHO was founded, today the landscape of global health is increasingly crowded. A growing array of governments, NGOs, private foundations, multinational corporations, public-private partnerships, and international organizations partake in public health related activities. One participant estimated that there are over two hundred such organizations currently in operation. Today s most important global health institutions such as the Bill and Melinda Gates Foundation, the Global Fund, the U.S. President s Emergency Plan for AIDS Relief, the World Bank, and Gavi account for a growing proportion of development assistance for health. These younger, more agile institutions far outspend the WHO, which has maintained a policy of zero nominal budgetary growth since the early 1990s even as it comes under pressure to broaden its portfolio to new areas, such as noncommunicable diseases and mental health. Voluntary contributions earmarked by donors for preferred projects have also surged as a share of the WHO s budget, which, some participants argued, has undermined its independence. For the WHO, the emergence of competent competitors points to a broader crisis of identity: what role should the WHO play in twenty-first century global health governance? In this regard, participants highlighted the tension between the WHO s political and technical roles. The WHO was originally established as the leading technical authority on health sciences. However, as an organization of member states, it is simultaneously a political organization. One participant noted that the WHO s human resources do not reflect its political character: nearly 50 percent of the organization s technical staff are doctors, but only 1.6 percent are social scientists, 1.4 percent are lawyers, and 0.1 percent are economists. Participants stressed that medical staff, though vital, are not trained to manage relations among states. As the Ebola outbreak demonstrated, such expertise is integral to managing cross-border infectious disease emergencies. To reconcile the tensions between the political and the technical, one participant recommended that the WHO be split in

5 4 two. Others noted that the WHO has long had difficulty attracting and retaining qualified, competent staff, particularly in regional offices. In the opinion of many participants, addressing these human resources deficiencies is among the WHO s most urgent challenges. In light of these longer-term trends a dwindling budget in real terms, an ever-expanding agenda, the emergence of competent competitors, a crisis of identity, and human resources challenges participants agreed that the WHO should identify its comparative advantages and set priorities accordingly. Many participants suggested that the WHO should coordinate emergency response to infectious disease outbreaks. Humanitarian organizations such as MSF are trained and equipped to launch responses to emergencies; the WHO should strive to facilitate their work. Beyond emergencies, many participants concurred that the WHO should set norms, collect and disseminate evidence and data, develop best practices, and build partnerships, particularly with the private sector, which will be critical to implementing the health-related Sustainable Development Goals in the years ahead. Despite its poor showing during the Ebola crisis, some participants maintained that the WHO continues to enjoy an unrivaled degree of legitimacy thanks to its universal membership and independence. The WHO should capitalize on this legitimacy to advance standards and norms that other global health platforms cannot. Moreover, despite the WHO s weaknesses, participants noted that there are pockets of excellence found across the organization. For example, one participant highlighted the successes of the strategic advisory group of experts (SAGE) on immunization, an independent group of experts tasked with advising on the WHO s immunization policy. SAGE reflects the WHO s unique ability to collect reliable data, provide technical guidance, and set global standards on immunization against infectious diseases. Participants agreed that the WHO should aim to replicate SAGE s success in other areas where it has a comparative advantage, particularly infectious disease surveillance and outbreak management. WHO REFORM: PRIORITIES AND PATHWAYS Workshop participants concurred that major reforms are necessary not only to strengthen global capacity to prevent, detect, and respond to PHEICs, but also to bolster the WHO s credibility. Several concrete recommendations emerged over the course of the discussion. Rather than create a new institution altogether, participants agreed that the WHO should be made leaner, more focused, and better equipped to coordinate and mobilize resources in the event of a PHEIC. To that end, many participants stated that the WHO should scale up its work in those areas where it alone can add value to the global health regime: coordinating global responses to international health emergencies, issuing technical guidance, setting standards and norms, and forging partnerships among governments, NGOs, and the private sector. One participant suggested that the WHO should strive to become a center of excellence for the collection and dissemination of public health data. Many participants affirmed that the WHO s regional structure is in urgent need of revitalization. The WHO s regional branches have long been plagued by politics and lack of accountability, the dangers of which were driven home by the Ebola outbreak. Several participants agreed that

6 5 specific criteria should be developed for regional directors to ensure that appointees are technically qualified. One participant went so far as to suggest that regional and country offices should be abolished altogether. However, others resisted this proposal, noting that regional directors and country officers can serve important roles. For example, one participant noted that the WHO s current representative in Syria has been vital to drawing attention to the dire state of public health in that country. Meanwhile, participants emphasized that the WHO should explore ways to eliminate disincentives to declaring PHEICs. For example, one participant said, governments and airlines that violate the IHR by imposing undue travel and trade restrictions on outbreak-affected countries should be censured. Many participants welcomed the WHO s swift progress toward establishing a global health emergency workforce and contingency fund, which the World Health Assembly endorsed in However, others argued that these measures merely amounted to tinkering, not true reform. In their view, the WHO s shortcomings are systemic: the culture is adverse to transparency, debate, and accountability. In this regard, participants highlighted the importance of robust leadership within the WHO and noted that WHO member states should prioritize it in the selection process Pervasive distrust between the WHO and the private sector may dissipate with the arrival of a new, more collaborative director general in for the next director general. Many suggested that a new director general will also be instrumental to fostering improved relationships with NGOs and the private sector. Several participants were highly critical of what they perceived as the current director general s hostility toward the latter. Participants stressed that the WHO should bring private sector companies to the table as partners, not as adversaries. Many agreed that the pervasive distrust between the WHO and the private sector may dissipate with the arrival of a new, more collaborative director general in Some participants argued that member states and large donors are responsible for compelling the WHO to implement reforms. They elaborated on this point by arguing that political leaders should elevate WHO reform in the Group of Seven (G7) and Group of Twenty (G20) because they are better positioned to shepherd reform than ministers of health. Others noted that German Chancellor Angela Merkel placed WHO reform at the top of the G7 agenda in 2015, but other pressing issues such as counterterrorism, economic stability, and conflicts in Syria and Ukraine received the lion s share of leaders attention. CONCLUSION The Ebola crisis not only served as a stark reminder that the World Health Organization is in need of institutional reform to safeguard against infectious disease threats, but it also shed light on the WHO s broader crisis of identity. Despite its shortcomings, the world needs an institution capable of monitoring international public health crises, issuing technical guidance, and building coalitions among governments, NGOs, and the private sector. Although the WHO will require major reforms, the Ebola outbreak may create the political momentum necessary to achieve them.