GOARN, global outbreak alert and response network; WHO, world health organization’s; MSF, medecins san frontier; UNMEER, u.n. mission for ebola emergency response

On January 25th a Special Session of the World Health Organization’s (WHO) Executive Board will be convened to discuss the Ebola emergency and the WHO response to the devastating epidemic that has specially affected several countries in West Africa during the last 18 months, causing thousands of deaths, decimating their economy and disrupting their social life.

It is the third time in the history of WHO that the Executive Board organizes a Special Session. This is evidently motivated by the hecatomb caused by this epidemic and by the multiple difficulties faced by the international response to the problem resulting in ineffective and untimely action.

This debate is happening too late within WHO Governance structure. Neither the Executive Board held in January 2014 nor the World Health Assembly held in May 2014 gave adequate attention to the matter. Notwithstanding, this Special Session will permit to pose some of the dilemmas faced by WHO in response to the Ebola emergency and help consolidate an effective response to the damages created by an insidious and lethal virus that, for decades, was relegated to the wild forest and rural environments but this time has painfully affected crowded urban settlements, situated in countries lacking the adequate health infrastructure and workforce which, otherwise, would have allowed its containment and the mitigation of its damaging effects.

The nature of the epidemic and the aggressiveness of the virus have certainly been unprecedented. However, the fight against Ebola has been full of mistakes and has lacked coordination. The affected countries’ health systems, chiefly Guinea, Liberia and Sierra Leone, WHO, the UN System and the International Community have been stumbling along. More than ever it is important to conduct an exercise of self-criticism and to call a spade a spade. It is important to identify the critical bottle necks that have impeded a more determined, effective and prompt action so the problem would not reach the proportion it has reached or the death toll that has been observed.

Decisions of major importance for the global health governance will be derived from the debate on the dilemmas faced, on the different options available and on the lessons learned about the successes and failures. It is a pity not to have and Independent Real Time Evaluation that would permit an objective and factual stock-taking of the problems that ought to be overcome. Notwithstanding, whatever is agreed will have to be ratified in May 2015 by the World Health Assembly and will influence in a decisive manner in the way crises like this will be faced in the future.

The matter is particularly sensitive since there is a risk of making even bigger mistakes either by omission or by inappropriate decision making. At the same time there is a unique opportunity for rectifying directions and improving the response capacity provided Member States and the WHO Secretariat articulate a visionary consensus on the changes that have to take place in the way of leading and managing these affairs in the future. So far this has not been the case.

Las week the WHO Secretariat issued two reports on the situation of the epidemic and on WHO’s response to it. They will be the main documents that will inform the deliberations of the thirty four Member States that are part of the Executive Board and the other Member States participating as Observers during the Special Session on the Ebola Emergency. The first one is titled “Current context and challenges; stopping the epidemic; and preparedness in non-affected countries and regions” (Document EBSS/3/2) and “Ensuring WHO’s capacities to prepare for and respond to future large-scale and sustained outbreaks and emergencies” (Document EBSS/3/3). It is important to read in detail the reflections and proposals made by the Secretariat in these documents, even though both of them are rather general in nature, not supported by formal evaluations, sometimes superficial in the analysis and vague or ambivalent in the proposals. Overall reflect a late WHO awakening to the need of putting its act together to fulfill some of its constitutional mandates related to public health emergencies and humanitarian crises.

In the weeks before the release of these two documents many worrisome ideas and opinions on the issues at stake floated in different media. This is the case of:

1. The frivolous idea of creating a new international agency for facing health emergency situations relegating WHO to a role of producing technical norms and standards but without any armed branches for orchestrating operational responses at country, regional or global level:
2. The proposal of creating an international health emergency response fund outside WHO; and
3. The idea of creating an international corps of emergency health workers managed outside WHO and not linked neither to the structures established by the International Health Regulations approved by 194 Member States in 2005 nor to the Health Cluster that is part of the International Humanitarian Response led by the United Nations in collaboration with Civil society and the Red Cross and Red Crescent Movement.

Evidently these absurd ideas have been triggered by the frustration resulting from the lack of an effective and timely response from the International Community at large, of the United Nation System and in particular of the WHO. However they point in the wrong direction fostering proposals that would only weaken the global health architecture and its current coordination mechanisms. If this path is followed there would be an even further atomization/balkanization of the already failed global health governance that has not dare to consolidate the necessary global public health goods needed in light of the globalization that characterizes the 21st Century. It is time to halt this trend and make the necessary steps for rationalizing the huge dispersion of channels and mechanisms associated to the global health partnerships created during the last 20 years at a high cost for the effective coordination of international public health.

It is interesting to note that a group of Member States that are part of the Executive Board, led by South Africa and the United states of America, have circulated a draft resolution with the idea of approving it during the Special Session of the Executive Board on the Ebola emergency on January 25th. The other countries that so far have adhered to this draft resolution are Chile, China, Cuba, France, Guinea, Liberia, Norway, Senegal, Sierra Leone, the United Kingdom, Zambia and Zimbabwe. It is a long resolution containing 9 preamble paragraphs and 36 operative paragraphs seeking to promote a consensus on the necessary reforms that are considered as vital for WHO’s adequate and effective functioning in emergency situations and extended outbreaks. A plea is made for having WHO consult on these matters with Member States, relevant non-State Actors and the UN System in preparation for the 68th World Health Assembly.

This draft resolution rightly proposes not only the need of reaching zero cases of Ebola Virus Disease but also of rebuilding the devastated health systems of the affected countries, fragile throughout the post-colonial period of their lives but especially decimated in Liberia and Sierra Leone following the internal conflicts and wars. These health systems are highly dysfunctional and certainly unable to comply with the core commitments made by all member States after the approval of the 2005 International Health Regulations. The draft resolution also seeks to reaffirm the specialized role that WHO ought to play in the response to outbreaks to natural disasters and in humanitarian crises triggered by conflict. It is mindful, in particular, of the role WHO ought to play as the leader of the health cluster in humanitarian health responses. It is good that the draft resolution bring attention to these matters because during the last years both the current administration of the Secretariat and some selected Member States have been rather short sighted and ambivalent in this connection, reaching even the point of relinquishing operational responsibilities in emergency response and favoring a vision of WHO as a merely normative agency. It is clear that WHO not Medecins San Frontier (MSF) is. Each organization has its role and hopefully a greater coordination, complimentarily and convergence between them can be developed. However, the worst mistake that could be made either by the WHO Secretariat of by Member States would be to conceive WHO as an ex-machina entity that only produces norms and standards but does not get the feet dirty in the tranches or in the direct operational action in support to Countries.

Clear reference is made by the draft resolution to the need of having WHO working on a better coordinated response, with greater linkages with the rest of the humanitarian system and other entities or organizations such as the African Union, the International Federation of Red Cross and Red Crescent Societies, MSF the United Nations System, especially the U.N. Mission for Ebola Emergency Response (UNMEER), the World Food Program. At the same time the draft resolution recognizes “the urgent need for an improved and more effective and coordinated response capacity for the international community and especially for WHO and Member States in responding to public health emergencies”

The draft resolution though, is rather weak in the operative paragraphs and does not drill down sufficiently nor discusses the changes that need to be implemented right away. It gets lost at times in formal aspects, such as the proposal of creating a post of Deputy Director for Ebola, instead of proposing a rationalization and reassignment of functions among current senior management. It does not make sufficiently explicit, with the level of clarity needed, the types of concrete actions that should be put in place and the reallocation of resources that will be warranted for making a real change of direction.

It is equally general in its proposals on health work force when this is one of the fundamental bottlenecks impeding the delivery of the adequate quality health care that can make a difference in interrupting the transmission of the virus and in reducing the case fatality rate of the disease. It is right in proposing that WHO should strengthen its capacity to coordinate the deployment of foreign medical teams and field hospitals in crises situations. Unfortunately, this has not occurred so far. The necessary strength, determination and convening capacity to make it happen has not been present. Interestingly enough, this is the fundamental strategy that should have been activated and potentiated since several months ago for effectively contain the epidemic in countries where there was no adequate health infrastructure or sufficient health workers.

The draft resolution is right in pointing at the huge problem represented by the fact that 70 per cent of the WHO Member States do not fulfill the requirement of core capacities for complying with the mandates of the 2005 International Health Regulations and request Member States to promote the inclusion of this aspect within the health goal that is being discussed as part of the Sustainable Development Goals for 2015.It also requests Margaret Chan, Director General of the World Health Organization, to prepare an analysis on options to make more decisive progress on this area and submit a report to the 68th World Health Assembly in May 2015.

The draft resolution that will be discussed on January 25th is in many ways an implicit admonition to the current administration of the WHO Secretariat. It states that the administrative and managerial processes have delayed many times the actions that should have been taken more nimbly. It calls for the creation of a Global Health Emergency Work Force including a global “on call” rapid response team ready to be activated in cases of outbreaks, disasters and other emergencies. The draft resolution though does not specify the criteria that should guide this new development. The initiative is important and is a necessary step but the devil is in the details and if it is not well thought it can end up being a chimeric and not very effective proposal. It will only crystallize if there is a clear will and a tangible commitment from Member States of making available their civil and military health assets and placing them at the disposal of a global mechanism coordinated by WHO. This will require more precise definitions and will have to be debated during the World Health Assembly in May. In addition, as highlighted by the draft resolution, it will be important that other initiatives advanced by the World Bank and the Global Health Security Agenda promoted by the government of the United States of America are aligned with the framework of the International health Regulations not opening parallel paths that may weaken the multilateral efforts led by WHO.

The draft resolution makes a call for adequately resourcing WHO to fulfill the mandate of Article 58 of its Constitution, creating a special fund to meet health emergencies and unforeseen contingencies, to be used at the discretion of the Executive Board. This would be fantastic but it remains to be seen whether Member States will really commit to finance it so it is not only a short term and non-sustained gesture of a handful of contributing countries.

Finally, the draft resolution asks the Director General of WHO to consider the establishment of an ad hoc advisory group within the framework of the Executive Board to provide administrative and logistical support in case of future outbreaks or emergencies. It also requests her to commission a panel of outside independent experts to conduct an analysis that should be brought to the consideration of the 68th World Health Assembly covering the following aspects:

1. How WHO organized its emergency response and the functioning of the Global Outbreak Alert and Response Network (GOARN) before the UNMEERR was created by the U.N. Secretary General, Ban Ki Moon, pursuant to the resolutions approved by the Security Council and the UN General Assembly;
2. How WHO has functioned within UNMEER and how effective has been the arrangement;
3. An analysis of the role chosen and performed by WHO during the Ebola epidemic: and
4. A review of WHO internal coordination including its three levels (HQ, Regional Offices and Country Offices).

All of this clearly shows that Member States are not satisfied with the way of doing business so far. It will be important to follow closely the deliberations of the Special Session of the Executive Board on the 25th of January. Member States ought to pronounce themselves with clarity on the above mentioned subjects. They should be critical with respect to the identified errors but they should also support the strengthening of WHO and the multilateral solutions. What are at stake are the rationalization of the global health governance and the support of those proposals that will avoid an unnecessary dispersion of mechanisms for having an effective humanitarian health response and an atomization of the fight against disease outbreaks.

None.

The author declares no conflict of interest.