Reforming WHO in a Time of Ebola

As a prelude to the 136th World Health Organization (WHO) Executive Board session (January 26-February 3, 2015), 36 countries and the EU member states drafted recommendations based on the WHO efforts in the ongoing Ebola epidemic in West Africa.  While the majority of the resolution affirms or reaffirms institutional dedication to addressing and managing the international response to the Ebola crisis in West Africa, several  recommendations and their corresponding deliverables, indicate a commitment to building an improved, more responsive WHO.  What follows is a summary of some of the most notable recommendations put forward to the Executive Board.

As noted in OP 39, the WHO acknowledges that “short-comings in…human resources systems and processes slowed down the Ebola response,” and this theme permeates many of their recommendations.  This draft resolution seems designed to prompt organizational change that will facilitate more efficient coordination, both within the WHO and with external stakeholders.  From developing mechanisms to increase emergency response workforce and capacity to implementing better screening and training processes for country representatives to independent review of the Ebola response, the language of the draft resolution indicates that organizational change may be forthcoming at all levels of the WHO.  Specifically, OP 2 clearly states the need to “accelerate ongoing reform of the Organization.”

Under the umbrella of improving leadership and coordination, several measures are recommended to provide the Director General with additional support to deal with large-scale response issues.  OP 5 recommends that the Director General consider appointing a Special Representative [1] to direct coordination at the county, regional and global levels and direct WHO response for the Ebola epidemic.  Additionally, OP 54 suggests establishing an advisory group “composed of operations experts from relevant stakeholders…to provide advice on administrative and logistical support” for future incidents.  The magnitude of the Ebola epidemic posed considerable challenges that the drafters determined to be beyond the capacity of the Director General to handle directly.  The resolution recommends that additional support to address response coordination from the outset of an incident would be beneficial, both in the context of the current Ebola response as well as for future public health emergencies. 

Another priority identified in the draft resolution is bolstering communication and information sharing capabilities. OP 9 specifically mentions the need for the WHO to “improve communication, coordination, and information sharing” with the UN Mission for Ebola Emergency Response (UNMEER) in order to support engagement by Member States. The resolution also requests that the Director General develop and improve mechanisms for international sharing of information on “diagnostic, preventive and therapeutic products” in order to improve the ability to rapidly employ them during an emergency.  In order to facilitate this, the resolution calls for creation of a global database of identified and stockpiled medical assets at the national and regional level (OP 32).  In light of the ongoing Ebola epidemic, it is recommended that the initial population of this database begin with hemorrhagic fevers.

Some of the suggestions reiterate previous recommendations from the 2011 International Health Regulations (IHR) Review Committee to strengthen the worldwide public health response workforce.  Specifically, OP 42 advocates developing a plan to establish and maintain “comprehensive emergency response teams” that can be deployed and sustained to support emergency response activities.  In particular, the recommendation lists three required capabilities of this surge program:

1.  Recruiting and training personnel to provide “internal surge capacity”

2.  Improving and expanding cooperation with organizations such as the Global Outbreak Alert and Response Network and Global Health Cluster to increase local public health capabilities

3.  Enhancing coordination with other United Nations agencies to provide scalable response

Additionally, OP 48 calls for the establishment of a contingency fund to respond to “the need for adequate resources for the preparedness, surveillance and response work of the [WHO].”  A report by the Director General to the 68th World Health Assembly will outline options for the scope, potential funding sources and other aspects of the contingency fund plan.  In addition to the 2011 recommendations, the resolution charges the Director General with formalizing agreements to provide use of existing surge capability and regional humanitarian aid, sharing available resources in order to decrease response time in future emergencies (OP 23).

As mentioned above, the WHO acknowledges that its internal processes hindered the progress of Ebola response in West Africa, and several of the recommendations call for review of some internal processes as well as the response effort as a whole, specifically citing a need for increased “transparency and reliability of health-related needs-assessment processes” (OP 10).  First, OP 52 recommends commissioning an independent assessment by a panel of experts on “all aspects of WHO response, from the onset of the current [Ebola] outbreak.”  This recommendation specifically calls out resource mobilization—a process, in particular, that delayed the initial WHO Ebola response—as requiring an investigation.  OP 53 requests that the Director General direct an internal review of the IHR with respect to “prevention, preparedness and response to the Ebola outbreak and the effectiveness of the IHR in facilitating that response.”  Of specific concern are the measures recommended by the 2011 IHR Review Committee that were and were not implemented and identifying future measures to “improve the functioning, transparency, and efficiency of WHO’s response…in future outbreaks.”  In addition to reviewing internal response policies and mechanisms, the resolution calls out the “selection, training and performance review” processes for Country Representatives (OP 40).  This recommendation even goes as far as to provide explicit support to the Director General in the use of her authority to “add or change staff…at the country or regional level,” indicating again a commitment to organizational change on multiple levels.

In addition to organizational reform designed to increase efficacy and efficiency of emergency response, the WHO affirms its role in guiding research and development of pharmaceuticals.  With respect to Ebola, the draft resolution calls for the Director General to maintain sustainability for the therapeutic drug and vaccine clinical trial working groups. Of specific concern are providing proper regulation under emergency conditions to ensure patient safety and developing “quality, safe, effective and affordable vaccines and treatments” (OP 33).  Furthermore, OP 34 addresses establishing priorities for Ebola-related research and appropriately utilizing data from clinical trials. This data will be valuable in determining the efficacy and safety of therapeutic drugs and vaccines; however, special consideration must be given to the limitations of studies conducted under current conditions.

There are many additional recommendations (57 OPs, in all); however, those listed above all bear the burden of specific deliverables. Many of them require some form of report, either to the 138th Executive Board or to the 68th World Health Assembly.  By delineating methods to ensure accountability, the WHO again illustrates its commitment to change and improvement. The outcomes of these recommendations will likely take months or years to come to fruition, and the magnitude of necessary changes and reorganization are not specified. It seems at this point, however, as though the WHO has good intentions in reviewing their actions and coordination over the course of the Ebola epidemic and implementing measures to improve future response.

 

1. On February 3, 2015, Dr. Bruce Aylward was named as the WHO Special Representative for Ebola Response.