WHO Under Microscope on Ebola, but Is Reform Likely?

Medical workers present Noubia, the last-known Ebola patient in Guinea, prior to her release from a treatment center. Conarky, Guinea, November 28, 2015. (Cellou Binani/AFP/Getty Images)

The sudden and unexpected reemergence of the Ebola virus in Liberia during November highlighted the need for continued vigilance against the deadly disease. Now a new report by an independent panel of global health experts is proposing a major reform agenda designed to prevent the next global outbreak, including a substantial overhaul of the World Health Organization (WHO).

The panel, convened by the Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine, offers both a strong rebuke of the international community’s response to the Ebola outbreak that began last year and an ambitious prescription for reforming the way it prevents, detects, and responds to disease outbreaks generally. But, at a time when the system of global health security is in crisis, how feasible are its recommendations? Will they measure up against political realities?

The report, published last week in the Lancet, is one of several major assessments underway designed to “strengthen our collective global health security,” as called for by United Nations Secretary-General Ban Ki-Moon during the UN’s General Assembly in September. It comes on the heels of the WHO-commissioned Stocking Report published in July and precedes the report of the UN High Level Panel on Global Response to Health Crises expected later this month. The report was prepared by 20 academics and public health experts including Peter Piot, who discovered the Ebola virus.

The document takes a wider view than the Stocking Report, representing a welcome attempt to look beyond the WHO’s remit to more clearly define the roles and responsibilities of multiple actors in global health governance, including national governments, donors, the UN, and private corporations. Amesh Adalja, a Senior Associate at the University of Pittsburgh’s Center for Health Security, told me the report offers a “stronger vision for global health security and reinforces what many have thought of the current response framework.”

As a consequence of this wider view, it does overlook some day-to-day operational challenges that played a role in the Ebola response, including the timely payment of community health workers. For this reason, those on the ground in the ongoing fight may be skeptical of the report’s vantage point.

“A Human Tragedy”

The report calls the Ebola epidemic “a human tragedy that exposed a global community altogether unprepared.” Although WHO Director-General Margaret Chan is not specifically mentioned, one panel member cites a “breathtaking absence of leadership” and “egregious failure” by WHO to sound the alarm in the summer of 2014, when the crisis was rapidly spiraling out of control in Liberia, Guinea, and Sierra Leone.

While the WHO receives the brunt of the criticism, it is made clear that there were problems at all levels of the response. These include a lack of clarity over who was responsible for coordinating international action, inadequate national investment and foreign donor support for building health systems within affected countries, disregard by governments and corporations of the WHO’s recommendations on trade and travel restrictions, and limited engagement with local communities.

“It was a global failure,” concluded panel member David Heymann, Head and Senior Fellow of the Center on Global Health Security at Chatham House, at an event on November 23rd.

Roadmap for Reform

The report provides 10 proposals for creating a more resilient system of global health security. One that is likely to gain traction—and which is also cited in the Stocking Report—is the establishment of a dedicated outbreak response unit within the WHO to coordinate action and provide surge capacity during a crisis. The organization is reportedly already taking steps to improve its operational capacity in this area.

A key message is a need for clear lines of accountability. To limit politicized decision-making, the creation of an accountability commission is proposed within the WHO comprised of independent experts rather than member state representatives. This would track resource flows and report to the UN and the World Health Assembly (WHA), which governs WHO activities through member state representation.

A separate proposal transfers responsibility for declaring public health emergencies from the director-general’s office to a standing emergency committee. According to Amesh Adalja, this committee would “allow a dedicated team of experts to be devoted to the issue at-hand,” and be “freer from distractions and extraneous considerations.”

Outside the WHO framework, a notable recommendation is the creation of a global health committee within the UN Security Council. The main goal would be to “elevate political attention to health issues posing a serious risk to international peace and security.” It would also address cases of non-compliance with the WHO International Health Regulations.

I have previously argued that there is a need for greater cooperation between the WHO and the Security Council to systematically monitor and asses health security threats and reinforce links between health and human security.  But, given the Security Council’s history of political gridlock and perceived lack of legitimacy, it remains to be seen whether it can command sustained global attention on these issues while avoiding becoming a proxy for the WHA’s political squabbles.

Resistance to Wholesale Change

The report also asks the WHO Executive Board to launch a “fundamental review” of the organization’s mandate and constitution starting in January of next year. This would seek to “substantially scale back its expansive range of activities to focus on core functions” and create a more focused and streamlined organization.

However, conflicts within the Executive Board and disagreements about what should constitute core and non-core functions seem likely to prevent a restructuring on this scale anytime soon. “A lot of the proposals that call for wholesale change will have difficulty,” warned Adalja, “The WHO is a bureaucratic agency that has many fiefdoms and structures that would need to be modified in order for [reforms] to be implemented fully.”

A great deal of faith is placed in the next WHO director-general—to be elected in 2017—to stand up to member states and other stakeholders and push through these reforms. One panel member suggested that a high-ranking political figure similar to former director-general and former Norwegian prime minister Gro Harlem Brundtland could be more successful in the role.

Some will accuse the report of doing too much. It proposes creating multiple new committees and organization-wide policies, and senior positions within WHO, with new levels of oversight. Instead of streamlining the organization, there is a risk of introducing even more bureaucracy, thereby decreasing its ability to quickly mobilize and implement responses to future outbreaks.

Nonetheless, the panel ultimately deserves credit for matching its rhetoric with a reform agenda that is big in scope but still attuned to the political realities of today’s embattled global health institutions. Looking forward, the report’s findings should be harmonized with the Stocking Report’s recommendations and feed into the forthcoming report of the UN high level panel. Efforts should be made to lobby the WHO leadership and other stakeholders in advance of the WHO Executive Board meeting in January 2016, before the critical window of opportunity for reform closes for good.