at law
World Health Organization Reform: Lessons Learned from the Ebola Epidemic by Lawrence O. Gostin
I
t was October 2014 and Ebola was raging out of control in Guinea, Liberia, and Sierra Leone. Margaret Chan, the World Health Organization’s director-general, defended the organization against charges that its response was late and ineffective: “We are a technical agency, with governments having first priority to take care of their people.”1 In January 2015, the WHO executive board undertook a systematic reform of the agency’s performance, and Chan again offered a defense: I followed protocol, leaving it to the Africa office (AFRO) to respond.2 Yet the three nations could not possibly have stemmed the outbreak alone, and AFRO was known to be dysfunctional. Ebola represents an inflection point requiring fundamental reform for the WHO. A failure of leadership will impact its status and legitimacy for a generation. Here, I offer five reforms that would transform it and ensure that it fulfills its constitutional mission as “the directing and coordinating authority on international health work.” 1. Ensure sustainable funding scalable to needs: the World Health Assembly should double the WHO’s overall budget, with mandatory dues comprising at least 50 percent within five years. Of the WHO’s 2014 to 2015 budget of $3.977 billion (supplemented by $572 million in emergency funds), only $930 million came from mandatory dues; 77 percent came from voluntary 6 HASTIN G S C E N T E R R E P ORT
donations that depended heavily on rich donors such as the Gates Foundation and the United States. Voluntary contributions are earmarked for the donor’s preferred projects, however, which are badly misaligned with the global burden of disease. For example, donors virtually ignore noncommunicable diseases, injuries, and mental illness. The agency’s budget is thus wholly incommensurate with its worldwide mandate. By comparison, the 2014 budget for the U.S. Centers for Disease Control and Prevention was $6.85 billion. The WHO’s financial position was not always so dire: only 48.8 percent of its 1998 to 1999 budget was from discretionary sources. The current reliance on voluntary donations has undermined the organization’s effectiveness and its flexibility to meet rapidly changing health threats such as Ebola. 2. Reform the WHO’s regional structure: empower the director-general to appoint regional directors and speak with one voice. WHO regional offices are uniquely independent within the United Nations system, having authority over regional personnel, including country representatives. Ministers of health elect the regional directors, whose allegiances are to the region rather than to WHO globally. Each region has its own budget. Most funding (except for the Pan American Health Organization) comes from the WHO’s central budget—depleting
the agency’s financial capacities while robbing it of the ability to speak with a unified voice and set a coherent global policy. During the Ebola epidemic, the director-general and AFRO fought for control, to the point that AFRO hindered international assistance—even in the face of a UN Security Council resolution. The WHO must speak and act coherently, which requires the directorgeneral to have control over the agency’s worldwide resources, workforce, norm development, and deployment in a global health emergency. Better alignment is consistent with the constitutional design, which envisions regions as “an integral part of the Organization.” 3. Empower major stakeholders to improve WHO governance: harness the creativity of civil society. A network of civil society organizations (CSOs) lamented that “we have little heard voices,” with the WHO failing to include them in governance. This state-centric focus sidelines valuable stakeholders—public, private, and philanthropic. Most CSOs have become disillusioned with the WHO, feeling that it does not welcome their participation and reflect their interests. Leadership means harnessing the resources and energy of key stakeholders. The distrustful relationship between the WHO and nonstate actors could be changed, to enlist stakeholders in a strategic alliance. Nonstate actors play no formal role in WHO governing structures. The assembly and board do not recognize stakeholders beyond states. This stance contrasts with that of the Joint United Nations Programme on HIV/AIDS, the Global Alliance for Vaccines and Immunisation, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, whose governing boards include civil society. The WHO makes it difficult for nongovernmental organizations to gain “Official Relations” status, which is prerequisite for nonvoting participation. Due to restrictive rules, virtually no southern-based CSO can participate in WHO governance. Rather than an antagonistic relationship, the WHO should harness the creativity of CSOs. March-April 2015
Civil society has lobbied governments to fund and support other international agencies, but not the WHO. AIDS changed the world, with civil society leading the fight for resources and political attention. That could happen with the WHO as well, but it would take major reforms. 4. Exert WHO’s constitutional authority as a normative organization: set an ambitious agenda of health treaties and voluntary codes. The WHO was created as a normative agency with incomparable powers to adopt health treaties and “soft” instruments.3 Yet in over sixty-five years it has adopted only two major health agreements—the International Health Regulations and the Framework Convention on Tobacco Control. The IHR guided the response to epidemic diseases ranging from severe acute respiratory syndrome and influenza H1N1 to polio and Ebola. The justification for norm creation is not simply that it is constitutionally mandated but also that it will drive change far better than technical support. Norm development can set the global health agenda, guide priorities, harmonize activities, and influence key state and nonstate actors. Yet the WHO has been reticent to venture into norm development. The Assembly has not passed a single resolution on the right to health. It even withdrew an innocuous right to health fact sheet in 2008 at the insistence of the United States.4 Just as tobacco and health security transcend borders, justifying the WHO’s Framework Convention on Tobacco Control and its International Health Regulations, so too do a range of major health hazards, such as noncommunicable diseases, mental illness, and injuries. By pressing normative development, the WHO could influence multiple stakeholders, much in the way the World Trade Organization has. 5. Build health system capacities in lowand middle-income countries: prevent the next global health emergency. What Ebola taught us is that highly preventable health hazards in states with fragile health systems can easily escalate in a world with hypercrowded cities, March-April 2015
intense human-animal interchange, and rapid air travel. Twenty-five Ebola outbreaks since 1976 have all been brought under control—except for this one. One difference is that the three affected states have particularly weak health infrastructures with few human resources. Also, this outbreak occurred in poor urban settings and in countries with cultural practices (in particular, certain burial rituals) that fueled the epidemic. And other Ebola-affected states have major health system problems too, for example, in the Democratic Republic of the Congo. The IHR requires states to develop their health systems while also asking richer countries to contribute, yet this legal mandate has never been enforced. Three discrete building blocks would help prevent the next epidemic. An emergency fund. The WHO should establish a contingency fund for use after a global health emergency is declared. A 2011 review of the H1N1 pandemic found that “[t]he world is ill-prepared to respond . . . to a global, sustained and threatening public-health emergency,” with the health capacities “not on a path to timely implementation worldwide.”5 The Review Committee on the Functioning of the International Health Regulations (2005) and on Pandemic Influenza A (H1N1) 2009 proposed a $100 million contingency fund, but the WHO failed to respond. Ebola showed that the fund would have to be several-fold greater, although that higher amount is still a modest investment with a high return. (Ebola will have cost billions, but could have been curtailed earlier with such a fund.) A global health reserve workforce. The WHO should maintain a reserve health workforce of highly trained professionals experienced in lower-income settings for deployment in a global health emergency.6 Among the main drivers of the Ebola epidemic was the absence of trained health workers to diagnose, treat, and isolate patients. A workforce reserve might also have reduced the deaths among domestic health workers. An international health systems fund. A longer-term, dedicated health system fund would build national capacities both to respond rapidly to emergencies
and to enable lower-income countries to deliver comprehensive health services. Governments would be expected to allocate domestic funds, fulfilling the 2001 Abuja Declaration pledge by African heads of state to allocate at least 15 percent of national budgets to the health sector. A sustainable international fund would help lower-income countries to build capacity to serve their entire populations. Robust health systems would not only improve health security but also shore up capacity to meet everyday needs such as child and maternal health, vaccinations, and essential medicines. The scale of a sustainable health system fund, however, would require a multibillion dollar investment channeled to lower-income countries, thus mobilizing the resources envisioned in the IHR, together with a right-to-health –based universal health coverage. The Ebola epidemic should spark a badly needed global course correction favoring strong health infrastructure. Sustainable funding scalable to needs for enduring health systems is a wise and affordable investment. It is in the interests of all states to contain health hazards that may travel to their shores. But beyond self-interest are the imperatives of health and social justice—a humanitarian response that would work, now and for the future.7 1. L. O. Gostin and E. A. Friedman, “Ebola: A Crisis in Global Health Leadership,” The Lancet 384 (2014): 1323-25. 2. S. Sengupt, “Effort on Ebola Hurt WHO Chief,” New York Times, January 6, 2015. 3. L. O. Gostin, Global Health Law (Cambridge, MA: Harvard University Press, 2014). 4. Global Governance Watch, “Observations of the United States of America on the ‘Right to Health, Fact Sheet No. 31’,” accessed May 31, 2013, www.globalgovernancewatch. org. 5. World Health Organization, Report of the Review Committee on the Functioning of the International Health Regulations (2005) in Relation to the Pandemic (H1N1) 2009 (Geneva, Switzerland: World Health Organization, 2011), http://apps.who.int/gb/ebwha/ pdf_files/WHA64/A64_10-en.pdf. 6. M. Barry and L. O. Gostin, “To Fight Ebola, Create a Health Workforce Reserve Force,” Los Angeles Times, September 18, 2014. 7. L. O. Gostin, “Ebola: Towards an International Health Systems Fund,” The Lancet 384 (2014): e49-e51 (2014). DOI: 10.1002/hast.424 H AS TI N GS C E N TE R RE P O RT
7
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
World Health Organization Reform: Lessons Learned from the Ebola Epidemic by Lawrence O. Gostin
I
t was October 2014 and Ebola was raging out of control in Guinea, Liberia, and Sierra Leone. Margaret Chan, the World Health Organization’s director-general, defended the organization against charges that its response was late and ineffective: “We are a technical agency, with governments having first priority to take care of their people.”1 In January 2015, the WHO executive board undertook a systematic reform of the agency’s performance, and Chan again offered a defense: I followed protocol, leaving it to the Africa office (AFRO) to respond.2 Yet the three nations could not possibly have stemmed the outbreak alone, and AFRO was known to be dysfunctional. Ebola represents an inflection point requiring fundamental reform for the WHO. A failure of leadership will impact its status and legitimacy for a generation. Here, I offer five reforms that would transform it and ensure that it fulfills its constitutional mission as “the directing and coordinating authority on international health work.” 1. Ensure sustainable funding scalable to needs: the World Health Assembly should double the WHO’s overall budget, with mandatory dues comprising at least 50 percent within five years. Of the WHO’s 2014 to 2015 budget of $3.977 billion (supplemented by $572 million in emergency funds), only $930 million came from mandatory dues; 77 percent came from voluntary 6 HASTIN G S C E N T E R R E P ORT
donations that depended heavily on rich donors such as the Gates Foundation and the United States. Voluntary contributions are earmarked for the donor’s preferred projects, however, which are badly misaligned with the global burden of disease. For example, donors virtually ignore noncommunicable diseases, injuries, and mental illness. The agency’s budget is thus wholly incommensurate with its worldwide mandate. By comparison, the 2014 budget for the U.S. Centers for Disease Control and Prevention was $6.85 billion. The WHO’s financial position was not always so dire: only 48.8 percent of its 1998 to 1999 budget was from discretionary sources. The current reliance on voluntary donations has undermined the organization’s effectiveness and its flexibility to meet rapidly changing health threats such as Ebola. 2. Reform the WHO’s regional structure: empower the director-general to appoint regional directors and speak with one voice. WHO regional offices are uniquely independent within the United Nations system, having authority over regional personnel, including country representatives. Ministers of health elect the regional directors, whose allegiances are to the region rather than to WHO globally. Each region has its own budget. Most funding (except for the Pan American Health Organization) comes from the WHO’s central budget—depleting
the agency’s financial capacities while robbing it of the ability to speak with a unified voice and set a coherent global policy. During the Ebola epidemic, the director-general and AFRO fought for control, to the point that AFRO hindered international assistance—even in the face of a UN Security Council resolution. The WHO must speak and act coherently, which requires the directorgeneral to have control over the agency’s worldwide resources, workforce, norm development, and deployment in a global health emergency. Better alignment is consistent with the constitutional design, which envisions regions as “an integral part of the Organization.” 3. Empower major stakeholders to improve WHO governance: harness the creativity of civil society. A network of civil society organizations (CSOs) lamented that “we have little heard voices,” with the WHO failing to include them in governance. This state-centric focus sidelines valuable stakeholders—public, private, and philanthropic. Most CSOs have become disillusioned with the WHO, feeling that it does not welcome their participation and reflect their interests. Leadership means harnessing the resources and energy of key stakeholders. The distrustful relationship between the WHO and nonstate actors could be changed, to enlist stakeholders in a strategic alliance. Nonstate actors play no formal role in WHO governing structures. The assembly and board do not recognize stakeholders beyond states. This stance contrasts with that of the Joint United Nations Programme on HIV/AIDS, the Global Alliance for Vaccines and Immunisation, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, whose governing boards include civil society. The WHO makes it difficult for nongovernmental organizations to gain “Official Relations” status, which is prerequisite for nonvoting participation. Due to restrictive rules, virtually no southern-based CSO can participate in WHO governance. Rather than an antagonistic relationship, the WHO should harness the creativity of CSOs. March-April 2015
Civil society has lobbied governments to fund and support other international agencies, but not the WHO. AIDS changed the world, with civil society leading the fight for resources and political attention. That could happen with the WHO as well, but it would take major reforms. 4. Exert WHO’s constitutional authority as a normative organization: set an ambitious agenda of health treaties and voluntary codes. The WHO was created as a normative agency with incomparable powers to adopt health treaties and “soft” instruments.3 Yet in over sixty-five years it has adopted only two major health agreements—the International Health Regulations and the Framework Convention on Tobacco Control. The IHR guided the response to epidemic diseases ranging from severe acute respiratory syndrome and influenza H1N1 to polio and Ebola. The justification for norm creation is not simply that it is constitutionally mandated but also that it will drive change far better than technical support. Norm development can set the global health agenda, guide priorities, harmonize activities, and influence key state and nonstate actors. Yet the WHO has been reticent to venture into norm development. The Assembly has not passed a single resolution on the right to health. It even withdrew an innocuous right to health fact sheet in 2008 at the insistence of the United States.4 Just as tobacco and health security transcend borders, justifying the WHO’s Framework Convention on Tobacco Control and its International Health Regulations, so too do a range of major health hazards, such as noncommunicable diseases, mental illness, and injuries. By pressing normative development, the WHO could influence multiple stakeholders, much in the way the World Trade Organization has. 5. Build health system capacities in lowand middle-income countries: prevent the next global health emergency. What Ebola taught us is that highly preventable health hazards in states with fragile health systems can easily escalate in a world with hypercrowded cities, March-April 2015
intense human-animal interchange, and rapid air travel. Twenty-five Ebola outbreaks since 1976 have all been brought under control—except for this one. One difference is that the three affected states have particularly weak health infrastructures with few human resources. Also, this outbreak occurred in poor urban settings and in countries with cultural practices (in particular, certain burial rituals) that fueled the epidemic. And other Ebola-affected states have major health system problems too, for example, in the Democratic Republic of the Congo. The IHR requires states to develop their health systems while also asking richer countries to contribute, yet this legal mandate has never been enforced. Three discrete building blocks would help prevent the next epidemic. An emergency fund. The WHO should establish a contingency fund for use after a global health emergency is declared. A 2011 review of the H1N1 pandemic found that “[t]he world is ill-prepared to respond . . . to a global, sustained and threatening public-health emergency,” with the health capacities “not on a path to timely implementation worldwide.”5 The Review Committee on the Functioning of the International Health Regulations (2005) and on Pandemic Influenza A (H1N1) 2009 proposed a $100 million contingency fund, but the WHO failed to respond. Ebola showed that the fund would have to be several-fold greater, although that higher amount is still a modest investment with a high return. (Ebola will have cost billions, but could have been curtailed earlier with such a fund.) A global health reserve workforce. The WHO should maintain a reserve health workforce of highly trained professionals experienced in lower-income settings for deployment in a global health emergency.6 Among the main drivers of the Ebola epidemic was the absence of trained health workers to diagnose, treat, and isolate patients. A workforce reserve might also have reduced the deaths among domestic health workers. An international health systems fund. A longer-term, dedicated health system fund would build national capacities both to respond rapidly to emergencies
and to enable lower-income countries to deliver comprehensive health services. Governments would be expected to allocate domestic funds, fulfilling the 2001 Abuja Declaration pledge by African heads of state to allocate at least 15 percent of national budgets to the health sector. A sustainable international fund would help lower-income countries to build capacity to serve their entire populations. Robust health systems would not only improve health security but also shore up capacity to meet everyday needs such as child and maternal health, vaccinations, and essential medicines. The scale of a sustainable health system fund, however, would require a multibillion dollar investment channeled to lower-income countries, thus mobilizing the resources envisioned in the IHR, together with a right-to-health –based universal health coverage. The Ebola epidemic should spark a badly needed global course correction favoring strong health infrastructure. Sustainable funding scalable to needs for enduring health systems is a wise and affordable investment. It is in the interests of all states to contain health hazards that may travel to their shores. But beyond self-interest are the imperatives of health and social justice—a humanitarian response that would work, now and for the future.7 1. L. O. Gostin and E. A. Friedman, “Ebola: A Crisis in Global Health Leadership,” The Lancet 384 (2014): 1323-25. 2. S. Sengupt, “Effort on Ebola Hurt WHO Chief,” New York Times, January 6, 2015. 3. L. O. Gostin, Global Health Law (Cambridge, MA: Harvard University Press, 2014). 4. Global Governance Watch, “Observations of the United States of America on the ‘Right to Health, Fact Sheet No. 31’,” accessed May 31, 2013, www.globalgovernancewatch. org. 5. World Health Organization, Report of the Review Committee on the Functioning of the International Health Regulations (2005) in Relation to the Pandemic (H1N1) 2009 (Geneva, Switzerland: World Health Organization, 2011), http://apps.who.int/gb/ebwha/ pdf_files/WHA64/A64_10-en.pdf. 6. M. Barry and L. O. Gostin, “To Fight Ebola, Create a Health Workforce Reserve Force,” Los Angeles Times, September 18, 2014. 7. L. O. Gostin, “Ebola: Towards an International Health Systems Fund,” The Lancet 384 (2014): e49-e51 (2014). DOI: 10.1002/hast.424 H AS TI N GS C E N TE R RE P O RT
7
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
