The World Health Organization (WHO) has a credibility problem, according to the recently released “Report of the Ebola Interim Assessment Panel.” The Panel of outside independent experts describes an under-resourced organization that is ill prepared for a global public health emergency and occasionally puts politics ahead of public health.
The Panel, which convened in March 2015, calls for immediate and comprehensive reform and offers a wealth of recommendations to strengthen the WHO’s preparedness and response capacity during a public health emergency of international concern (PHEIC), such as the ongoing Ebola pandemic. However, past experience suggests that the organization and its member governments should take a more piecemeal approach by evaluating and prioritizing recommendations based on their political feasibility as well as their technical merits. In particular, the establishment of a $100 million contingency fund and changes to the organizational culture should be prioritized ahead of the creation of an independent center for emergency response.
Establishing A Center For Emergency Preparedness And Response
The Panel advocates establishing a WHO Center for Emergency Preparedness and Response that would be headed by a “strong leader” with “full operational authority” and accountable to an “independent board.” These features would presumably give the center autonomy from the rest of the WHO, empowering it to make decisions that are evidence-based and serve the local population while insulating it from the self-interests of donor and regional governments.
Independence is a good idea but a politically unfeasible one. Member governments are unlikely to fully cede control over disease surveillance or sole authority to sound the alarm in a suspected PHEIC to an independent center within the WHO. For example, it took nearly a decade before member governments in 2005 formally permitted the WHO to collect and act on reports of disease outbreaks from non-governmental sources. A pseudo-independent emergency center would likely be given enough autonomy to impede coordination and exacerbate turf wars but not enough to withstand political pressure from governments. It risks being a disappointment in future global public health emergencies, which would further undercut trust and confidence in the WHO and fuel suspicions that the organization is beyond repair.
Centralizing Emergency Funding And Decision Making
The Panel also recommends centralizing WHO emergency funding and decision making by giving the director general discretion over a $100 million contingency fund. The Panel notes that additional contingency funding would expand the organization’s rapid response capacity and make it easier for the director general to plan and access funds. The director general could also presumably use the contingency funds to improve coordination by imposing a division of surveillance, containment, and field response tasks across WHO staff and other United Nations (UN) and non-UN partners.
Further, the Panel recommends that senior management would be given more authority over regional and country offices so WHO staff would be less beholden to regional governments — a factor that the Panel finds delayed the WHO from sounding the alarm during the ongoing Ebola pandemic. During emergencies, the Panel writes, “reporting lines would switch” as WHO regional and country emergency teams would report to the head of WHO emergency operations in Geneva.
A $100 million contingency fund under the director general’s control is particularly valuable and feasible. Donor governments have not sufficiently contributed to the fund since it was first proposed by a 2011 WHO internal review. But the current pandemic is exerting sufficient pressure to cajole donors to increase their contributions.
Centralization of decision making is less politically viable. The last time centralized decision-making happened in 2001 it was modest and occurred only after protracted negotiations with developing countries who were (rightly) protesting that centralization increases the relative influence of donor governments. Developing countries may not acquiesce this time. Some regional governments are already suggesting that a lesson of the Ebola emergency is that regional governments should have more—not less—influence over the WHO’s response.
Transforming The Organizational Culture
The panel also calls for a “transformation of its organizational culture” whereby management and staff assume—if not embrace—that they are not just part of the supporting cast but “the lead health emergency response agency.” This proposed culture shift would be transformational.
As late as last September, Director General Margaret Chan described the WHO as a technical agency not a leader in global emergency response — even though the organization has a mandate to lead. Still, Chan defended the WHO’s initial response to the pandemic as appropriate for an organization contributing primarily technical assistance to affected countries.
The director general’s understanding of the operational mission also informed the institutional culture — a culture that impeded a concerted response. According to the Panel, prior to the outbreak, few staff planned for a “large-scale, long-term, multi-country emergency response.” During the response, the Panel added, decision making was reactive and sluggish. Staff prioritized their relations with regional governments ahead of scaling up emergency action. “Open and critical dialogue” was rare between senior WHO leaders and staff so essential but politically-sensitive information, such as reports of new infections, reached decision makers belatedly.
The report finds that a more emergency-oriented culture would empower and encourage staff to take calculated risks and timely decisions as well as pass along all relevant information and adjust their work quickly. The Panel welcomes Chan’s “plan for an expanded and stronger Global Health Emergency Workforce” and recommends training more WHO staff for emergency response as well as conducting regular simulation exercises and post-emergency joint evaluations. The WHO would designate standby staff, adopt policies that facilitate rapid deployment, and create frameworks for action so a staff member “knows exactly what he or she is to do in an emergency.”
But culture change requires more than structural reforms, and here the report is thin. In particular, the director general should reinforce structural reforms by demonstrating her own commitment to the leadership mission. In April, WHO senior executives acknowledged that reform was needed so the WHO could take its “rightful place” in emergency response. Yet they did not acknowledge that this rightful place was leading it, if national authorities lack the capacity to do so.
Chan needs to state unequivocally that the WHO has a leadership role during emergencies and to develop a vision detailing the contribution of WHO leadership to global public health. Ideally, the vision would mobilize additional resources and unify the staff or at least incentivize them to identify their own contribution. Development of the vision should start with a listening tour so staff can take some level of ownership and propose reforms aligned with the vision. The process should also help identify operational gaps, internal divisions of labor, and any opposition, giving Chan time to rally proponents.
Further, the director general should signal her backing for regional and country-level staff that may have to challenge national authorities during an outbreak. She could send this signal by taking an action where she pays a nontrivial political cost to improve WHO emergency response. For example, she may pursue centralized decision making where she risks paying a political price with regional governments. Alternatively, she could shame donor governments that do not sufficiently contribute to the contingency fund or violate the (2005) International Health Regulations — the framework for preparedness, surveillance, and response for disease outbreaks.
Overall, these changes are modest in the face of a threat like the ongoing Ebola pandemic. Yet incremental change is sometimes the best course given political realities at the WHO and the complexity of the global public health system.