Course Correction: WHO Reform after Ebola

Coauthored with Daniel Chardell, research associate in the International Institutions and Global Governance program at the Council on Foreign Relations.

Reforming international organizations is no easy feat. Before meaningful institutional change can occur, something awful often has to happen. The financial crisis of 2008 provides a case in point: only when leaders stared into the abyss did they begin to revamp the regulatory regime underpinning global economic stability.

Something similar may be happening today in global public health. As the unprecedented Ebola epidemic abates in West Africa, the World Health Organization (WHO) could be on the precipice of its own post-crisis reformation.

Gathering for a special session on Sunday, the WHO Executive Board—the organization’s thirty-four-member agenda-setting body—unanimously adopted a resolution calling for sweeping, long overdue institutional reforms to bolster the agency’s rapid response capacity. Among other provisions, the resolution endorses the creation of a reserve of public health workers, supported by a $100 million contingency fund from which the WHO could draw in case of a “public health emergency of international concern” (PHEIC), such as the Ebola epidemic.

These institutional innovations could begin to remedy the shortfalls that impaired the WHO’s initial response to the epidemic, which has claimed more than 8,600 lives since March 2014. As this blog previously noted, the outbreak revealed just how poorly equipped the world was to contend with an epidemic-prone virus, particularly in a region with weak public health systems. The WHO was MIA during the early months of the outbreak, having gutted its emergency response and surveillance units due to budgetary shortfalls from donor states. The WHO failed to declare the epidemic a PHEIC until August 8, 2014, by which time the virus had spread to Nigeria, Africa’s most populous country, and claimed nearly one thousand lives in Guinea, Liberia, and Sierra Leone.

At the height of the outbreak, the WHO became an easy target for criticism—and rightly so, to a degree. In September 2014, Margaret Chan, director-general of the WHO, maintained that her organization was “not the first responder,” but merely a “technical agency.” National governments, she asserted, had “first priority to take care of their people and provide health care.” The comments were maddening, not least because the countries in question—Guinea, Liberia, and Sierra Leone—lacked the capacity to tackle the outbreak on their own. Prior to the Ebola epidemic, Guinea had an estimated ten doctors per 100,000 people, Sierra Leone had two, and Liberia had only one.

Consider how much more effective the international response to Ebola could have been had the WHO possessed its proposed cadre of trained, paid, and equipped health workers last year. It could have deployed this force to the hot zone promptly rather than recruiting volunteers on an ad hoc basis after the outbreak had reached epidemic proportions. Such a force would also have reduced the WHO’s reliance on the manpower of nongovernmental organizations, such as Médecins Sans Frontières (MSF, or Doctors without Borders), which courageously sought to fill the void left by the WHO. MSF deserves praise for being among the first to recognize the severity of the Ebola outbreak and to mobilize resources to combat it, but NGOs cannot and should not be expected to manage international health emergencies. Ultimately, NGOs should complement the work of the WHO—not vice versa.

The outbreak also exposed the systemic vulnerabilities of the WHO’s business model. For decades, the WHO’s agenda expanded even as member states’ assessed dues remained static, leading it to become increasingly reliant on voluntary sources of funding, including from philanthropic foundations, nongovernmental organizations, and private donors. These external contributions were often earmarked for specific projects, such as polio eradication and chronic illnesses, making it hard for WHO leadership to set clear priorities and strategic direction. Meanwhile, the WHO increasingly competed with other multilateral institutions like the World Bank—as well as well as new frameworks like the Global Alliance for Vaccines and Immunizations (GAVI) and the Global Fund for AIDS, Tuberculosis and Malaria—for leadership and funding for global public health. More recently, the global financial crisis led states and voluntary donors to cut their contributions, leading the WHO to halve funds dedicated to emergency response in its 2014–2015 budget [PDF].

Voluntary contributions of course should be welcomed, but they are inherently vulnerable to sharp year-to-year swings. The Ebola crisis showed just how tragic the consequences of financial shortfalls can be—and the need to put the WHO on a firmer financial footing, beginning with a stand-alone pool of funds available to respond to a PHEIC. The Executive Board’s proposed $100 million contingency reserve begins to fill that gap, providing a permanent source of funds that would remain independent of external circumstances, such as economic downturns and the whims of donors.

Tragically, the Ebola crisis might have been averted had the WHO and its member states simply heeded earlier (supposed) “lessons learned.” In 2011, a committee charged with taking stock of the WHO’s response to the 2009 flu pandemic, known as H1N1, found [PDF] the WHO to be “ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.” The WHO’s capacities, it noted, were designed for “relatively short-term, geographically focal events,” not prolonged, international public health crises. In other words, the WHO’s emergency response systems were unfit for the challenges that lay ahead in a world where humanity increasingly confronts novel pathogens that can travel the world like carry-on luggage. The review committee went on to recommend that the WHO create a contingency fund and a global health workforce—exactly the steps that, four years and thousands of lives later, the WHO has finally begun taking.

The Executive Board’s belated endorsement of these recommendations could begin the long effort to restore the WHO’s credibility and leadership in global public health. In recent years, governments and civil society actors frustrated by the WHO’s institutional shortcomings have been tempted to bypass the body, developing ad hoc multilateral arrangements to advance public health goals. Sunday’s decision could start to reverse that trend.

Much work remains to be done, however. The reforms endorsed by the Executive Board should be welcomed, but they are not a panacea. Before the reforms can be implemented, they need the imprimatur of the World Health Assembly, the WHO’s decision-making body, which convenes for its annual session in May. Moreover, the proposed contingency fund of $100 million is by itself insufficient to stave off future pandemics. Consider that the global response to the Ebola outbreak—which, notwithstanding a handful of cases in Europe and North America, has been largely confined to West Africa—has cost more than ten times [PDF] that amount in humanitarian response alone.

Perhaps more importantly, the crisis teaches that building up the WHO’s own ability to neutralize PHEICs is only part of the battle. The WHO and its member states must focus in parallel on strengthening the national capacities of weak countries themselves to respond to epidemics. At present, only sixty-four [PDF] WHO member states have met their core public health capacity requirements under the 2005 International Health Regulations (IHR), a binding agreement that requires all countries have the ability to prevent, detect, address, and contain potential public health emergencies. Under the current framework, countries self-report to the WHO on their compliance with IHR core capacity requirements. Time and again, this system has proven inadequate. The initial June 2012 deadline to come into full compliance has since been extended twice, and 25 percent of all countries have failed to initiate communication with the WHO altogether.

As Director-General Chan said before the Executive Board on Sunday, the IHR “need more teeth.” To accelerate implementation of the IHR core capacity requirements, the Obama administration in February 2014 launched the Global Health Security Agenda (GHSA), which has since garnered the support of more than forty countries worldwide. This is a promising development. But the GHSA is not a universal arrangement, nor does it enjoy the legitimacy accorded to the IHR by merit of the WHO’s global representation.

The Ebola crisis underscored that the world is not only economically interdependent, but epidemiologically so. As horrific as the Ebola outbreak has been, an influenza pandemic holds the potential to take a far greater toll. Only after the WHO takes stock of lessons learned from the Ebola crisis, initiates sweeping reforms, and shepherds universal implementation of the IHR core capacity requirements will the world be on a surer public health footing.