5

Challenges in Design of
Governance for Global Health

This chapter focuses on applying what WHO and member states have learned about governance design from the challenges of the West African Ebola crisis, as well as other epidemics, to addressing future infectious threats. Workshop participants examined recent proposals for enhancing global preparedness and response to health emergencies, in regards to both the WHO system and other global health actors, and considered how existing global security initiatives and frameworks can coordinate their efforts to create more synergy and avoid gaps in communication, workforce, and resources.

WORLD HEALTH ORGANIZATION

Margaret Chan noted how the West African Ebola crisis illustrated challenges faced by all responders to infectious disease outbreaks, described the weaknesses and shortcomings it revealed in the world’s outbreak preparedness and response capacities, and highlighted successful outcomes as well as setbacks. Highlighting the elusive spread of the virus in Guinea and then Liberia and Sierra Leone in early 2014, Chan stated that no type of ideal governance design can manage the invisible. Therefore, in order to truly leverage the International Health Regulations (IHR), every country must be able to detect potential outbreaks. However, it can be extremely difficult for countries measuring mortality and morbidity rates to pinpoint a disease like Ebola in the midst of deaths from Lassa fever, yellow fever, typhoid fever, dengue, and cholera, making early disease detection challenging. Chan, like many other speakers and discussants, noted the failure of the IHR 2005 during the Ebola crisis and the lack of established core

capacities for early disease detection, timely and transparent notification, and response on the part of Guinea, Liberia, and Sierra Leone. Conversely, she observed that when Mali, Nigeria, and Senegal experienced their first imported cases, these governments quickly caught them, launched an emergency response, and prevented or swiftly curtailed transmission. Chan acknowledged that the challenges WHO faced during the Ebola crisis fall into three broad categories:

• The absence of national detection and response capacities, compounded by poor infrastructure for both transportation and communication;
• Weak preparedness and response capacity within the international community, including extremely limited surge capacity; and
• The conflict between sovereignty and collective action against a shared threat.

The problems created by the third category of conflict between the rights of sovereign states and the need for global solidarity represent the highest barrier to global health governance, according to Chan. She noted several examples from WHO’s recent experience that illustrate this point:

• The government of a country affected by Ebola refused to issue visas to some members of a WHO response team. They were eventually approved, but precious time was lost.
• One government abruptly decided to report only confirmed cases of Ebola, not suspected or probable cases as required by WHO, highlighting potential mismatches in reporting when looking across geographic regions.
• Many countries imposed traffic and trade restrictions that isolated the three affected countries and vastly increased their hardship. Several airlines suspended flights to West Africa, impeding the arrival of response teams, equipment, and humanitarian aid.
• WHO advised against certain extreme control measures shown to be ineffective, if not counterproductive. However, neither WHO nor any other external authority can dictate what happens within a sovereign state.

Ultimately, leadership—including command and control—by the presidents of the three affected countries helped to control Ebola, but community engagement was decisive, Chan reported. When people understand and own a problem, they carve out their own socially and culturally acceptable solutions, she observed, such as how to isolate ill people from the healthy. Community engagement was far more effective than quarantines enforced

by armed military personnel, she argued. With 32 laboratories deployed to the 3 affected countries and Nigeria, the speed and precision of diagnostic testing gradually approached levels in wealthy countries, Chan said. Data collection and reporting also improved considerably, but it is still far from perfect, she added. The numbers of treatment beds increased quickly, as treatment centers were built by Médecins Sans Frontières (MSF), followed by WHO, both working beyond their usual roles.

Future Directions

Looking to the future, WHO engaged in several research projects to improve outbreak response over the course of the crisis, according to Chan. They inventoried the qualifications and skills of Foreign Medical Teams (FMTs) and created a register for matching response needs to those who can meet them most efficiently. WHO also developed Ebola-specific personal protective equipment by bringing together manufacturers and experienced clinicians to select designs that offer maximum protection for the health care workers yet allow clinicians to work in reasonable comfort under very hot and humid conditions. An Ebola vaccine appears imminent, thanks to a broad effort involving the people of Guinea and scientists working with partners around the world, including WHO (Henao-Restrepo et al., 2015). WHO has also prequalified four rapid point-of-care diagnostic tests for Ebola.

Based on lessons learned in this epidemic, WHO is creating a blueprint for research and development during outbreaks of high-risk pathogens, Chan reported, which features a generic clinical trial protocol, arrangements for fast-track regulatory approval, and expedited development of new medical products.¹ “All of these achievements were made possible by the unprecedented collaboration of multiple partners,” she said, noting by example a field laboratory constructed in collaboration with 19 institutions and partners in two major networks.

Chan urged all involved to be honest and learn together, so that changes driven by this epidemic make it possible not only to get to and maintain zero, but also to help the affected countries rebuild their health systems. Managing the global regime for controlling the international spread of disease is a central and historical responsibility of WHO. But while they have extensive experience and vast networks of collaborating laboratories and institutional partners, the organization’s current assets are insufficient to manage a disease event that is unexpected, severe, and sustained, she reported. Chan did note that informal arrangements existing between WHO and the UN Secretary-General for activating all assets within the UN system to address urgent health problems have been engaged to control H5N1

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¹ More on research and development during outbreaks can be found in Chapter 6.

avian influenza, the 2009 influenza pandemic, and the West African Ebola outbreak. These arrangements are now being formalized under the guidance of David Nabarro, she said. She also briefly highlighted WHO’s ability to work in unison across regions, in their relationship with the Economic Community of West African States (ECOWAS), a subregional group to address the challenges across the seven regions instead of within each individually.

WHO’s Global Health Security Role

A few participants asked whether Chan accepted WHO’s perceived responsibility for promoting and maintaining global health security as legitimate, especially considering the operational or interference implications that responsibility may have in certain circumstances. Formally, the Director-General cannot interfere in sovereign states, Chan acknowledged, but she said she has spoken regularly with the presidents of Guinea, Liberia, and Sierra Leone, as well as with those of Mali, Nigeria, and Senegal, saying it is necessary to intervene at that level. As an example of this, Chan described an occasion when the president of an affected country demanded that a planned mobile laboratory be sent to his constituency rather than the location WHO had chosen. “I pick up the phone, talk to the president. I said this cannot happen,” she reported. “So I do interfere, but I don’t go on a microphone.” Government leaders are very receptive if you talk to them privately about honoring their commitments, she concluded, whereas public approbation inevitably misfires.

The duty of the Director-General is, first, to tell governments that they need to take responsibility for their citizens’ care, and second, to be a good global citizen and not export problems to other countries, Chan stated. At the same time, she added, national governments facing health emergencies must recognize that they cannot serve their people’s needs without assistance. She added to previous comments regarding the proliferation of the health field and advocated for including nonstate actors, such as civil society and communities, academics, and the private sector, and encouraging open dialogue, transparency, and accountability. Regarding appropriate circumstances for WHO to take an operational role, Chan replied that the organization had, on many occasions, mobilized and coordinated assets from around the world. In some instances, WHO has been “the provider of last resort,” but only to an “absolutely failed state,” she explained, noting that they always get the support of civil society or governments.

The West African Ebola crisis—unlike the hundred or so outbreaks that involve WHO each year—outstripped the organization’s response capacity and that of many others, Chan observed. Ebola taught lessons that can prepare the world for a crisis on that scale or larger, such as an influenza

pandemic, she said. “We are not there yet, and Ebola is just a warm-up exercise,” she warned, cautioning that the next pandemic is certain to come.

Perspectives from External Partners

In addition to Chan’s internal critique of WHO and discussion of relevant future opportunities to explore, other speakers also added their external perspectives. Highlighting difficulties in IHR compliance, the disagreement on potential roles of WHO, and the complex structure of the UN system, speakers and participants explored various design options for future governance changes for global health.

Chatham House Report

In 2012, two working groups, which included several participants in the current workshop, were established by Chatham House to examine the topics of global health financing and governance.² Charles Clift of Chatham House reported that there was very much less agreement concerning what sort of restructuring of WHO might or might not be desirable or indeed possible. The report reflects those differing opinions and includes recommendations crafted by Clift alone, he explained. Because it was completed well before news of the West African Ebola outbreak had circulated widely, the report did not tackle WHO’s role in that event, but it instead provides an overview of reforms the organization could undertake in order to better fulfill its overall mandate.

Clift pointed out that WHO’s efforts to help member states meet the core capacity provisions of the IHR has not only been unsuccessful, but it does not directly address the organization’s potential role in a disease outbreak, as distinct from any national response. To address this perceived deficit, the Chatham House report recommends that one of WHO’s core functions should be promoting and maintaining global health security—a responsibility that includes preparedness for health emergencies, supporting the implementation of the IHR, and polio eradication, as well as outbreak response, he noted.

WHO’s appropriate role in outbreaks is the subject of a longstanding debate that has intensified with the Ebola crisis, as Clift observed (Farrar, 2015; Garrett, 2015; Gulland, 2014; WHO, 2015b). As Chan noted—and

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² For the full reports of these working groups, see “What’s the World Health Organization For?” (Clift, 2014) at https://www.chathamhouse.org/sites/files/chathamhouse/field/field_document/20140521WHOHealthGovernanceClift.pdf (accessed April 18, 2016) and “Shared Responsibilities for Health: A Coherent Global Framework for Health Financing” at https://www.chathamhouse.org/sites/files/chathamhouse/field/field_document/20140521HealthFinancing.pdf (accessed November 30, 2015).

disputed—in her presentation, many among the general public and the press believe that WHO should be staffing frontline operations. “WHO is the UN specialized agency in health, we are not the first responder. . . . [T]he government has first priority to take care of their people and provide health care,” she told The New York Times in September 2014 (Fink, 2014). She added that WHO is a technical agency and is unlike international nongovernmental organizations (NGOs), the Red Cross, or similar agencies who are working on the ground to provide direct services.

If WHO has a limited role to help countries deal with their own problems, it is surprising that the organization designed and built Ebola treatment centers, Clift remarked. But if there is no one to coordinate, then the question arose of whether or not WHO should step in to execute the work. If that is the case, should that become a core function? Clift wondered. In order to judge whether WHO’s efforts in the Ebola crisis were successful or not, Clift attempted to define WHO’s responsibilities and set boundaries for their work, noting that much of the criticism of WHO stems from unrealistic expectations. He offered the following points under the heading, “What Should WHO Be Doing?”:

• At all times provide expert advice to governments on the implementation of the IHR, in particular the core capacity requirements for surveillance and response.
• Work with affected governments, and provide expert advice, to understand what external help they need to deal with an outbreak.
• Coordinate the supply of expertise and materials that governments need to supplement their own efforts, drawing on resources from member states and other donors, the Global Outbreak Alert and Response Network (GOARN), FMTs, and others.
• Mobilize financial resources from member states and donors in sufficient time and commensurate with country needs.
• Ensure effective and timely coordination with the UN system and its Global Health Cluster.³

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³ The UN’s response to humanitarian crises is organized according to nine thematic clusters, each led by a UN agency. The agency functions as “provider of last resort” and is accountable to the UN Humanitarian Coordinator. The aim of the cluster approach is to strengthen partnerships and ensure more predictability and accountability in international responses to humanitarian emergencies, by clarifying the division of labor among organizations, and by better defining their roles and responsibilities within the key sectors of the response. The nine clusters, together with their lead agencies, are Nutrition (UNICEF), Health (WHO), Water/Sanitation (UNICEF), Emergency Shelter (UNHCR/IFRC), Camp Coordination/Management (UNHCR/International Organization for Migration), Protection (UNHCR/OHCHR/ UNICEF), Early Recovery (UNDP), Logistics (WFP), and Emergency Telecommunications (OCHA/UNICEF/WFP). Clusters can be activated in response to both sudden emergencies as well as ongoing emergencies. See more at https://business.un.org/en/documents/249 (accessed January 8, 2016).

• Fulfill obligations in the IHR regarding potential public health emergencies of international concern, including prior to a formal declaration.

Several commentators identified WHO’s three-tiered structure—in which international, regional, and national offices frequently act independently of each other—as an impediment to its response to Ebola, Clift said. As Gostin and Friedman (2015) have noted, “the poor cohesiveness between headquarters (HQ) and AFRO⁴ became evident during Ebola. AFRO did not convene health ministers or open a regional coordination centre until 3 months after Ebola was confirmed in Guinea; the Guinea country office reportedly impeded aid and technical assistance.” To some extent, this incoherence reflects conflicts that arise between the individual interests of its member states and the cause of global public health, as previously described by both Fineberg and Chan. Also, as Fineberg and other commentators have pointed out, regional WHO offices are autonomous, permitting each to adapt to local conditions but obstructing their coordinated participation in global disease response under WHO’s direction (Fineberg, 2014). This lack of coordination in the face of an epidemic like Ebola has created buzzwords of “command and control” and raised the prospect of an outbreak-response force convened by WHO (or perhaps another organization) that could suddenly operate with military speed and efficiency, Clift said.

Questioning his own conclusions regarding WHO’s structural deficits, Clift acknowledged that he had yet to see an objective analysis of what WHO actually did wrong in the West African Ebola epidemic. Some might cite the late declaration of the public health emergency of international concern (PHEIC) as one such shortcoming, he added, although he then expressed the belief that an earlier declaration was unlikely to have changed the response on the ground. “It may be true that we can contemplate better structures and governance for WHO that appear more efficient, but the underlying political relationships and conflicting interests between WHO and member states, or between different actors at the different levels of WHO, are not necessarily transformed simply by introducing a command and control operation alongside WHO’s existing decentralized structure,” Clift suggested. Moreover, he questioned whether WHO could effectively combine both decentralized and centralized modes of operation, and whether a command-and-control organization is politically and practically feasible.

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⁴ WHO Regional Office for Africa.

A U.S. Government Perspective

Colin McIff of the U.S. Department of State considered ways to make WHO and the UN health governance system more effective and efficient during health emergencies. From the outset, he maintained that the United States stands behind WHO’s leadership and its role as the agency poised to lead and coordinate the international response to global health emergencies. At the same time, McIff emphasized that U.S. support for WHO in this role—and that of other governments—is not unconditional. He characterized this post-Ebola period as a singular opportunity to make WHO “fit for purpose”—capable of mounting an effective response to outbreaks and other health emergencies—but predicted that the international community will be compelled to seek solutions elsewhere if this attempt fails.

The U.S. government endorses and supports WHO’s efforts to launch a global health emergency workforce, and also the creation of a new global contingency fund to underwrite WHO’s initial response to a global health emergency, approved by the World Health Assembly (WHA) in May 2015, McIff stated. However, WHO currently lacks the capacity, institutional systems, and corporate culture to meet the above mandates, he observed. Thus, reforming WHO stands as an important collective opportunity for the global health community. Even so, the U.S. government believes that WHO should coordinate and mobilize the envisioned global health emergency workforce, which would incorporate GOARN, a new robust platform for managing FMTs, and WHO’s role as Health Cluster lead in humanitarian response, he explained. McIff depicted the global workforce as a collection of specialized capacities, each of which would retain their independence and be called on only as needed. WHO—as that organizational core—would not be expected to “do everything” in the event of a health emergency, he noted, but rather would be poised to ensure the timely deployment of appropriate international capacity as need arose. The UN had previously implemented a response framework for humanitarian emergencies that is well known and accepted, according to McIff. Extending this model and taking a collective, “whole-of-agency approach” to all emergencies “is going to be very critical,” he observed. The U.S. government advocates the creation of a structure containing all assets within outbreak preparedness and humanitarian response, in order to deliver a unified “all hazard response,” he said.

McIff noted that it remains to be determined what “command and control” means in the context of WHO’s decentralized structure. Although western countries might favor emergency response to be directed from the organization’s international HQ, he noted, his South African colleagues

at “Friends of WHO Emergency Reform”⁵ argued that bypassing WHO’s regional offices would amount to “cutting out the countries where many of these emergencies and disasters are taking place.” Countries at highest risk for infectious outbreaks want a transparent understanding of the command-and-control structure and chain of command, and they rightly want regional directors to be included and be held accountable for their decisions, he explained.

McIff concluded his presentation with a list of next steps to be taken in the development of a WHO-led emergency response network:

• Establishing distinct human resource and information technology systems within WHO to support the rapid mobilization of emergency response teams.
• Creating long-term and systematized relationships between WHO and its key partners in emergency response, particularly within the broader UN system. He noted that ad hoc agreements between WHO, the World Food Programme, and the United Nations Children’s Fund (UNICEF) were significant to the Ebola outbreak response and should be made permanent and systematic, “so that in the next crisis we are not trying to figure out where air bridges are going to come from or who will develop the community mobilization strategy and how that will relate to public health needs.”
• Designating a special representative with organization-wide authority to implement timely decisions in response to an emergency, as eventually was done on an ad hoc basis during the Ebola crisis.
• Developing recommendations, informed by discussion at the 2015 WHA and analysis by its Ebola Interim Assessment Panel (2015), to organize the broader UN system to respond to health emergencies, including deployment of proposed World Bank financing.

The U.S. government agrees with the general view that WHO’s declaration of a PHEIC in the Ebola crisis was late, particularly given the slow international response that followed it, McIff stated. This situation suggests that health ministries—not to mention prime ministers’ offices and ministries of finance and other affected sectors—may not understand what a PHEIC means, he observed. Changes must be made not to replace national leadership in these offices, but to allow such leaders to do their jobs, he asserted.

At the 2012 WHA, “we didn’t do anything unfortunately to mobilize on the Fineberg recommendations,” McIff recalled. That has changed, he said, and the WHA is now putting forth a sustained effort to address global health threats. He also noted that there is more money available to support

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⁵ See http://www.who.int/about/who_reform/emergency-capacities/NFR_Informalconsultation_21July.pdf (accessed January 8, 2016).

the WHA’s commitment to fully implement the IHR in West and Central Africa and in other at-risk states by 2019, and all parties should take advantage of the momentum. The G7 recently made a similar commitment involving 60 countries, and the United States has designated more than $1 billion for capacity building in 30 countries, he reported, with additional funding expected from European countries.

ROLES AND RESPONSIBILITIES OF GLOBAL HEALTH ACTORS

McIff noted that the Global Health Security Agenda (GHSA)⁶ provides another opportunity to strengthen core capacity and health systems. He reported that more than 50 countries now participate in the GHSA, many of which were motivated to participate by the potential benefits for their health systems. These countries view the GHSA as a way to nationalize and incorporate the IHR into their health systems in meaningful ways, he said. The United States views the GHSA as an accelerant for the IHR, not a parallel system, McIff stated. Beyond supporting the development of core capacities specified in the IHR, the GHSA should encourage good practices (e.g., peer-review system assessments) in participating countries that potentially can be universalized through WHO, he added.

Thiermann, whose previous description of the OIE’s voluntary peer-review PVS Pathway contrasted with that of the IHR’s self-assessed mandate for core capacity, reviewed several reasons why he believes the OIE’s approach has had greater success. First, all 180 of the OIE’s member countries, including 52 African nations, were engaged in developing the PVS Pathway. Second, evaluation is voluntary and occurs at the request of the country. Third, the primary goal of the mission is to address the country’s disease burden, not to detect emerging diseases that cause alarm for external countries. The resulting improvements in animal health, public health, and food security benefit both the prevention and detection of emerging infectious diseases. Incentives for reporting outbreaks counteract the potential impacts on trade and expedite calls for assistance.

Combining Public Health and Humanitarian Systems

Regarding global health security, López-Acuña insisted that it is WHO’s overriding purpose and responsibility to maintain it. Stocking characterized WHO as the guardian of global public health, managing health emergency responses and alerting the global health community to threats. McIff also emphasized WHO’s preeminence as a coordinator of the many institutions that together ensure global health. He added that WHO should not try to

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⁶ See http://www.globalhealth.gov/global-health-topics/global-health-security/ghsagenda.html (accessed January 4, 2016).

replicate MSF or the U.S. Centers for Disease Control and Prevention or other institutions that have capacity to respond, but WHO should continue to take a strong coordinating role and deploy resources as needed in a responsive way. Takemi noted the lack of alternatives to WHO as the coordinator of global health emergency response, and that no concrete suggestions have been put forward for collaboration between the UN humanitarian system and WHO. Stocking added that much remains to be done to develop an effective, timely outbreak response plan to coordinate both entities, as the humanitarian side is unfamiliar with the IHR, and the WHO side does not understand the humanitarian response network infrastructure. She described the UN Mission for Ebola Emergency Response (UNMEER) and said it should be seen as a last resort (a position McIff also endorsed, on behalf of the U.S. government).

Humanitarian–health collaboration is an ongoing challenge and a problem that WHO in particular must address as part of its process of internal reform, McIff observed. “It’s not necessarily about squashing the two sides together,” he said. “It’s about making sure that they can function effectively and communicate effectively with one another while carrying out their distinctive mandates.” There is also a need to break down barriers between animal and public health, McIff stated. Interest in animal health and its impact on trade are a major reason countries are interested in the GHSA, he observed.

Gostin summarized the consensus view of the IHR and the role of WHO in health emergency response, saying that most believe the IHR is a useful governing instrument, but the lack of compliance has caused most of the problems. Several participants had also advocated the need for an empowered WHO, Gostin observed. “We have to understand what its essential functions are and make it fit for purpose, but the WHO is needed,” he said. But regarding leadership, as illustrated in the earlier exchange among Chan, Fineberg, and Liu, Gostin agreed that national sovereignty cannot be overcome by international structures such as WHO. The conflict between collective action and sovereignty as it applies to the IHR is something that must be managed with foresight and planning, well in advance of a health emergency, Gostin argued. Stocking added that the UN Secretary-General’s panel may be the best place to address the sovereignty question.

WHO as an Emergency Responder

Peter Daszak of EcoHealth Alliance expressed concern that an emergency response function for WHO would be expensive to establish, and would create similar tensions within the organization as occurred between WHO and NGO responders during the Ebola crisis. Given the growing frequency of spillover events from wildlife, outbreaks will become pandemics

more often and have greater economic impact, he predicted, and he thought it might make more sense to design a response force specifically to address major pandemics—more than just a unit within WHO. Clift disagreed, saying the expense of setting up a new institution is prohibitive, unless it is absolutely necessary.

Stocking noted that her panel concluded that the emergency response function in WHO should report to the Director-General, who decides when to announce a PHEIC. It remains to be decided how WHO fits into the wider emergency response system, she continued, but a likely scenario is already employed by the United Nations, whose humanitarian agencies mostly coordinate work done on the ground by non-UN responders (e.g., international NGOs, local NGOs, and governments). “There is already a lot of cooperation,” she observed, and her panel felt that WHO needed to join existing systems of coordination.

Global Health Emergency Workforce

The global health emergency workforce could be comprised of separate components for infectious disease surveillance and detection, and for emergency response operations, both of which could serve as engines for capacity building, McIff observed. Such an opportunity presented itself when the African Union deployed health teams to West Africa to deal with a common threat to security, he noted, but better communication between WHO and the teams could have allowed them to work more effectively together.

Elias of the Gates Foundation encouraged examination of other health workforces to guide the development and organization of an emergency response entity, saying that too often discussions of governance tend to be top down and retrospective in nature. For example, the WHO polio workforce in Nigeria, with a staff of more than 2,200, along with more than 10,000 UNICEF-employed community mobilizers, is close to having eliminated the disease, he reported. Reasons for this success include political and technical leadership, but also the contribution of traditional and cultural leaders in dispelling fear in their communities, “silo-busting” collaboration among people attending to different aspects of the response, and operational flexibility.

Similarly, Elias suggested an in-depth case study on challenges faced and overcome by responders to the 2014 polio outbreak in Syria last year. There are some lessons to be learned about how good leaders taking assertive action in an imperfect governance system have actually solved some very important public health problems, he said. While a “top-down and theoretical discussion” can be useful, he observed, it must be balanced with accounts of obstacles that have been overcome in real-world environments to achieve success in public health.

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