Guest Editors: Joshua Busby, Karen A. Grépin and Jeremy Youde
In March 2014, the World Health Organization (WHO) was officially notified about cases of the virus in Guinea, however, it was not until early August 2014 that the WHO declared the outbreak a Public Health Emergency of International Concern. As of February 17, 2016, there have been more than 28,000 cases of the disease and over 11,000 deaths.
A belated international response headed off worst case scenarios, but that effort was seen by many to have been too slow. While West Africa is now virtually Ebola-free, with occasional cases popping up now and then, the region’s weak health infrastructure makes it susceptible to the recurrence of Ebola and other potential disease outbreaks.
The Ebola crisis has highlighted global disparities in health resources, both human and financial, as well as the need to reform the global health governance system to be better able to respond to future outbreaks. And although Ebola is the most prominent disease to catch international attention, other outbreaks, such as the current cases of MERS and the Zika virus also pose important threats to global health governance.
There have been no less than six reviews that have tried to assess what went wrong during the Ebola crisis including one by Harvard/London School of Hygiene & Tropical Medicine, an independent panel commissioned by WHO itself, and a review by a special UN panel. Many of them point to the need for important reforms to both the WHO, the International Health Regulations, and wider system of global health. These recommendations include creating new politically-insulated offices and committees to assess health emergencies, establishing funds to permit rapid emergency responses, incentivizing states experiencing disease outbreaks to report to WHO in a timely manner, and creating financing facilities to encourage treatment and pharmaceutical research.
At the 2015 World Health Assembly meeting, some of these reforms were set in motion, namely creating a $100 million emergency response fund (funded by voluntary donations from member-states) and directing the Director-General to form and coordinate a global health emergency workforce. As Mackey and Clift note in their contributions to this issue, some of the major recommendations, including an increase in the assessed dues to the WHO, were explicitly rejected by member-states. This leaves the WHO with the perennial problem of being dependent on voluntary contributions from donors for their pet projects and priorities, leaving the essential functions of global health surveillance potentially underfunded.
WHO Reform – Disappointing Recommendations
Despite the time and energy put into the various review efforts, the likelihood of seeing meaningful and far-reaching changes being implemented is negligible at best. Most of the recommendations offered by the review panels are either unworkable or unlikely to be implemented. Director-General Chan called for member-states to increase their assessed contributions by 5 percent. This would be the first increase in mandatory dues since the early 1980s, and it would give WHO significant fiduciary flexibility to set its own budgetary priorities. During the 2015 World Health Assembly, though, member-states rejected this modest increase in assessed contributions. While they did permit an increase in the organization’s overall budget, they mandated that this rise be financed only through voluntary contributions.
Another proposal called for the creation of a WHO Centre for Emergency Preparedness and Response to develop and coordinate efforts to address health emergencies. This would seemingly duplicate existing efforts and offices, both within and outside WHO, and add additional layers of bureaucracy without appreciably increasing the organization’s response capabilities. It might give the appearance that the organization was “doing something,” but it would likely complicate the ability to implement timely responses. Furthermore, many of the suggestions designed to increase WHO’s emergency response capabilities proceed from a narrow definition. They prioritize responses to actual infectious disease outbreaks, but they neglect strengthening the underlying health systems themselves. In general, the recommendations themselves are not bad, but they may overlook the political context and fail to appreciate the processes by which any such reforms would actually be implemented.
Particularly absent is a serious discussion of strengthening underlying health systems. These, and not an emergency operations fund or a rapid deployment of health workers, are the real first lines of defense against the emergence and spread of an infectious disease outbreak. The crisis has been seen as a failure of the global community to provide sufficient support of strengthened health systems and has led to calls for Universal Health Coverage, but as Harman argues below this movement has not been privileged in the past relative to other priorities and is unlikely to generate sufficient political priority going forward to make any meaningful change. McCollum and Taegtmeyer’s perspective supports this argument in that a previously devastating outbreak of cholera in Sierra Leone led to similar calls but that the lessons from that outbreak were largely ignored and that led to the same mistakes being repeated again this time around.
WHO Leadership Transition
Margaret Chan’s second five-year term as Director-General will expire in 2017, and the selection of the organization’s next leader will say much about its future trajectory. Chan has received significant criticism for her failure to bolster the organization’s legitimacy. Given how dependent WHO is on voluntary contributions, it faces a perilous future unless it can convince the international community that it possesses the authority and legitimacy to effectively coordinate and lead responses to the health concerns facing the world. The next director-general must inspire confidence, demonstrate a level of political savvy, and maintain the trust of a sprawling organization whose effectiveness is dependent upon the good relations between the central office in Geneva and the six autonomous regional offices.
Like other UN specialized agencies, WHO follows an informal process of regional rotation in selecting its leadership. All of the Director-Generals since 1973 have come from either Asia or Europe, so there may be strong pressure to select someone from Africa or Latin America. Michel Sidibé, the executive director of UNAIDS, and Awa Coll-Seck, the Senegalese Minister of Health and executive director of the Roll Back Malaria Partnership, have both been mentioned as possible candidates. Another person whose named has been mooted who has expertise and credibility is Agnes Binagwaho, Rwanda’s Minister of Health. There may be a desire for someone with more experience in politics in the hopes that that person could have more influence with government officials in member-states, particularly with donors. Graçea Machel, who chairs the Partnership for Maternal, Newborn, and Child Health and who has chaired the GAVI Alliance Board, might be an intriguing choice with such stature.
Whoever is appointed to lead the organization going forward, that person has to make the case to the international community that WHO merits more regular and reliable sources of funding for the core functions like disease surveillance and early warning that only a global organization can carry out. At the same time, WHO’s new leader needs to make the case that global investments in health systems strengthening beyond West Africa are necessary to ward off the next possible global pandemic. If past experience is any guide, these sorts of reforms and legitimacy rebuilding require a leader who both possesses a level of comfort with the dynamics of global public health and has the political savvy to work with policymakers from around the world to acquire more core contributions to WHO’s budget. Finding both in a single leader can be tricky, but it is not impossible. Gro Harlem Brundtland, who served as Director-General between 1999 and 2003 and had a medical background before entering electoral politics, may be the model for what the World Health Organization needs in a leader over the next five years.
The urgency of this has been underscored by the rapid emergence of the Zika virus. Zika went from an obscure mosquito born virus affecting Brazil to being declared by the WHO a Public Health Emergency of International Concern (PHEIC) in February 2016, because of the disease’s rapid spread throughout the Americas and its association with microcephaly, a birth defect affecting the head and brain size of babies in the womb.
Beyond health systems strengthening, the Zika crisis underscores the need for finance for health technologies for emergent global health threats. The Flannery et al. contribution to this volume provides a set of criteria by which to think about which health threats should receive priority finance. They focus on those that are easily transmissible through the air or through human-to-human contact, that could kill large numbers of people, and for which there are market failures that impede technology creation in the absence of public action. Interestingly, Zika, because it does not kill large numbers and is largely transmitted by mosquitoes, would not fulfill their criteria, though birth defects arguably provide a reason for its inclusion but potentially opens up demands for finance for many other insect-borne diseases.
The Special Issue
In this special issue, we bring together academics and experts to think critically about what the Ebola outbreak and the response to it tell us about global health governance and its future. The authors take on a variety of different elements, looking at the International Health Regulations, the role of regional organizations, encouraging international cooperation on health emergencies, the role of the military, and the lessons we can learn from other disease outbreaks. We put forward no specific answers, and we took a decidedly catholic approach to this issue, but we aim to generate discussion and deep thinking about what the international community can learn from this outbreak so that it does not repeat the same mistakes and shortcomings in the future.
Sophie Harman – “Norms won’t save you: Ebola and the norm of global health security”
In this commentary, Sophie Harman argues that stronger norms in support of the International Health Regulations (IHR) would not necessarily have prevented the Ebola crisis nor would they shield the world from future crises. She notes that norms exist in a global hierarchy of other normative commitments and that some are more resourced than others. For example, efforts to supply anti-retroviral drugs were also championed by norms entrepreneurs, and that campaign has generated significant flows of resources to support universal access, a material sign of its status in the hierarchy of global norms. Other norms-driven health causes such as the Millennium Development Goals and polio eradication also are privileged relative to support for IHR compliance. The WHO, she argues, is too weak to generate political (and therefore material) support for health systems strengthening, at the heart of IHR compliance, leading to the conclusion that norms won’t save people suffering in health crises.
Andrew Price-Smith and Jackson Porreca – “Fear, Apathy, and the Ebola Crisis (2014-15): Psychology and Problems of Global Health Governance”
Price-Smith and Porreca offer a unique perspective on the problems facing global health governance structures by adding a psychological component to the equation. The institutional impediments that block a more effective response to global health emergencies, they argue, arise out of what they term the “fear/apathy cycle.” Epidemic outbreaks breed a high degree of fear, which leads to inappropriately draconian policies and ostracization of those afflicted. When the emergency passes, though, the international community retreats into a sense of complacency. We lurch between the extremes of responses rather than finding some sort of consistent vigilance that would provide the global health governance architecture with the strength and resilience necessary to respond to any unforeseen emergencies. Their argument suggests that many, if not all, of the reform proposals being put forward to improve future responses to disease outbreaks will have little purchase because they fail to address this underlying psychological conundrum.
Charles Clift – “Ebola and WHO Reform”
Drawing on his extensive experience working with governments and international organizations on global health matters, Clift’s commentary highlights structural flaws within the World Health Organization. In particular, he focuses on the complications that emerge from having a lead organization simultaneously coexist with strong, autonomous regional organizations. One of the key flaws in WHO’s Ebola response was the failure of cooperation between WHO’s central headquarters in Geneva and the Regional Office for Africa. Looking at the various reform proposals that have come out so far, he laments the fact that they fail to resolve this underlying tension and instead attempt to bypass the structures altogether. He raises a question that few member-states appear willing to address: does WHO’s decentralized structure inhibit the organization’s ability to be effective?
Maryam Deloffre – “Human Security Governance: Is UNMEER the Way Forward?”
In her article, Deloffre explores the differences between a traditional state-centric response to security and a human security one. She then analyzes the extent to which the UN Mission for Ebola Emergency Response (UNMEER) constituted one form or another. Human security responses tend to be people-centric and focus on a wider range of threats than state security approaches, bringing in a wider number of actors through bottom-up processes of consultation than top-down state security efforts. UNMEER facilitated an unprecedented array of cooperative activities, but Deloffre argues that the specific health security frame conformed to more traditional state-centric notions that made coordination more of a challenge and that perhaps foreclosed some bottom-up measures that could have ameliorated impacts on vulnerable populations and brought human rights concerns more to the fore.
Timothy Mackey – “Lessons from Liberia: Global Health Governance in the Post-Ebola Paradigm”
In this commentary, Mackey examines the experience of Liberia in confronting the Ebola crisis and the implications for the WHO, the International Health Regulations, and global health governance going forward. He concludes that the Inter-Agency Health Team, a multi-stakeholder partnership, was quite helpful in coordinating the response between Liberia’s government, different actors in the U.S government, and the WHO. However, this mechanism was created as an ad hoc response, lacking a formal process for generating such partnerships if needed in the future. Liberia’s weak health system made the country vulnerable to Ebola, and insufficient support from the WHO for IHR compliance did not shore up this weakness. Mackey concludes the piece with five important reflections and observations on progress (1) on the need for a more flexible WHO budget with resources for emergencies, (2) that WHO’s decentralized structure needs remedies that do not appear to be on the agenda as yet, (3) that the criteria for declaring a PHEIC be revised including a possible intermediate alert, (4) that more resources and attention be paid to compliance with the IHR, particularly on disease detection, reporting, and rapid response, and (5) finally, that resources be made available for an emergency workforce that can be tapped as needed.
Rosalind McCollum and Miriam Taegtmeyer – “Let’s not make the same mistake again: A political economy analysis of Sierra Leone’s Cholera and Ebola epidemic responses”
McCollum and Taegtmeyer draw parallels between the Ebola outbreak and a recent outbreak of cholera that infected over 25,000 people in Sierra Leone (and bordering Guinea) in 2012. Using a political economy issue analysis, they identify structural issues that were common to both outbreaks. While they identify weak health systems as a key factor that led to both epidemics, McCollum and Taegtmeyer argue that many of these issues were related to structural weaknesses, such a weak public management system and a lack of trust of citizens, within the health system rather than simply a low level of total resources to support the health system. To learn from these lessons, they argue that the government needs to find ways to better engage with communities and to strengthen accountability for health service delivery.
Jessica Flannery et al. – “A Process for Defining Priority Diseases for a Research and Development Financing”
Flannery et al. note that until the 2015 crisis, the Ebola virus received insufficient attention in terms of disease diagnostics and therapeutics. There have been calls for the creation of an international financing facility that might generate health technologies for diseases in the future. She and her colleagues identify the criteria that would make a disease eligible for inclusion in the financing facility’s purview, namely that there are (1) high fatality rates, (2) the disease is easily transmissible, and (3) that there are insufficient market incentives to provide technologies because the disease disproportionately affects communities with low purchasing power and in cyclical outbreaks. In their review of a variety of lists of diseases, Flannery et al. conclude that in addition to Ebola, the diseases in scope for inclusion are the Machupo virus, Marburg, MERS, the Nipah virus, and SARS. These criteria would largely exclude neglected tropical diseases and a number of other diseases such as dengue and Chikungunya.
Alexandra Kaasch – “The Ebola crisis and health systems development”
Kaasch analyzes the early donor contributions to the Ebola outbreak and notes that while there is nearly universal agreement that weak health systems contributed to the outbreak and that many high level declarations have been made about the importance of strengthening health systems, most of the aid provided to heavily affected countries in the immediate aftermath of the outbreak likely did very little to support health systems in the long run. She argues that current donor support mechanisms are likely inadequate to deal with health system strengthening needs and instead argues that new financing structures, which could operate at different levels are more likely to be successful in addressing future threats.