The Ebola Outbreak: Catalyzing a “Shift” in Global Health Governance?

Influenza viruses evolve in two different ways including antigenic “drift” (e.g. small genetic mutations occurring continuously over time) and “shift” (e.g. major, abrupt changes/reassortment leading to different virus subtypes with high virulence and pandemic potential) [4]. This evolutionary process presents significant challenges in developing therapeutics and vaccines, as well as responding with appropriate public health measures, as viruses adapt to their environment and traverse multiple animal and human hosts. Similar to the “drift” that occurs in viral evolution, previous disease outbreaks of SARS (2002), H1N1/A (2009), MERS-CoV (2013), and the ever-looming threat of highly pathogenic influenza (e.g. H5N1), precipitated the current crisis in global health governance now occurring post-EVD [5‐8]. Criticism has been swift, including strong statements from several heads of state, key civil society actors, national governments, and academia, opining on the need to pursue more radical reform measures, primarily focused on the future of WHO [9‐13]. These developments could mark the beginnings of a “shift” in the evolution of global health governance.

Despite the need for a revitalized WHO, reforms supported by WHO’s own high-level Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies (WHO Advisory Group, established by the WHO DG in July 2015), whose role was to provide guidance in relation to WHO’s emergency reform process (including the recommendations issued by the various panels), did not recommend some of the major changes advocated by the panels [47]. Instead, at the January 2016 WHO Executive Board meeting (coinciding with WHO declaring that EVD was no longer a PHEIC) , the WHO Advisory Group recommended critical enhancements focused on WHO internal outbreak and health emergency management, but did not recommend larger structural governance changes. Specifically, the group recommended the widely supported establishment of a centrally-managed, separate, dedicated WHO global Programme for Outbreaks and Emergencies headed by an Executive Director having its own budget and workforce that reports to the WHO DG [36, 47]. WHO would leverage the formation of this internal mechanism to also engage in other reform measures including ensuring greater health stakeholder collaboration, establishing better operational/ business processes during outbreaks, calling for an increase in member state assessed contributions for emergencies, capitalizing a contingency fund for emergency response, and improving resource mobilization, political engagement, accountability and external oversight [36, 47].

Following up on the WHO Advisory Group’s recommendations, at the 69th WHA in May 2016, Member States approved a plan formally establishing the WHO Health Emergencies Programme with a structure in many ways identical to that proposed by the WHO Advisory Group [48]. Accompanying its formation was an increase of $160 million to the existing WHO programme budget for WHO’s work in health emergencies, establishment by the DG of an independent oversight and advisory body, and the announcement of the appointment of Dr. Peter Salama (formerly with UNICEF) as the inaugural Executive Director [49]. Other reform recommendations that the WHO leadership has committed to carrying out or that are in the process of being implemented include the creation of a global health emergency workforce, strengthening implementation and monitoring of IHR core capacities, funding of the $100 million contingency fund for emergencies (via voluntary contributions including US$26.60 million received as of May 2016), and the development of an “R&D Blueprint” for accelerating R&D for health emergencies [49, 50].

Specific to the need for greater coordination and acceleration of R&D for vaccines, drugs, diagnostics, delivery systems, and other health technologies to avert a future epidemic when no existing medical countermeasures exists, the WHO published its “Plan of Action” for its R&D Blueprint on May 2016 [51]. This document presents the preliminary strategy for the WHO R&D Blueprint, as originally requested at the 68th WHA, and envisions a central convening and coordinating role for WHO in health R&D, a concept supported in different forms by all of the panels [51]. Though the Plan of Action envisions an inclusive and collaborative global approach to tackle the lack of R&D preparedness and access to treatment made evident during the EVD outbreak, it is unclear how this framework will be funded, implemented, and whether it will be aligned with existing governance structures and other related proposals. This includes existing structures such as the UN High-Panel on Access to Medicines and other financing and normative instruments currently being explored (including the WHO TDR Health Product Research & Development Fund and a proposed Global biomedical R&D treaty) [52].

More importantly, though the creation of WHO’s new Health Emergencies Programme represents a critical internal governance “drift”, structural reforms that would represent the needed governance “shift” to modernize WHO continue to lack the necessary political will and financial support for what would likely be a much more expensive reform process [14]. For example, restructuring of WHO’s current HQ/regional office/country office organizational structure has not been seriously considered, with the focus instead on bolstering staffing and support for WHO country offices and relying on the newly formed Health Emergencies Programme to enhance coordination [14, 38, 53]. The importance of restructuring WHO-led coordination (between WHO HQ, regional and country offices, and other support channels) was made evident by the lack of sufficient communication and coordination between WHO HQ and its largely autonomous regional office AFRO, a factor identified as contributing to the spread of EVD [13, 53].

Additionally, a needed increase and stabilization of WHO’s core budget (an 8% increase in voluntary contributions was approved at the 68th WHA but a 5% increase in member state assessments for the core budget was not; and a recent October 2016 WHO financing dialogue including a proposal by DG Chan to raise assessed contributions 10% received mixed reactions/support) has not been carried out, despite universal recommendation from all the panels on the need for more sustainable financing. Further, though the US$160 million increase in WHO’s budget to fund the Health Emergencies Progamme (which remains only 56% funded as of Oct 2016) is a needed investment, it falls far behind the CGHRF recommended annual investment of $4.5 billion to strengthen global infectious disease capacity []. Finally, though the WHO adopted a Framework for Engagement with Non-State Actors (FENSA) at the 69th WHA following 2 years of intergovernmental negotiations, the structure of the framework is limited to operational procedures and engagement management, and has also been criticized by certain stakeholders [14, 54, 55]. As such, it will likely fall short in establishing robust partnerships and creating a much needed space for formal interactions between WHO and critical non-state actors clearly needed during health emergencies.

Growing recognition of the importance of global health and the unremitting threat of an emerging infectious disease outbreak may make it untenable to simply wait and hope for a sufficiently reformed WHO. Instead, the lasting legacy of the EVD outbreak may be its foreshadowing of a governance “shift” in formal sharing of the complex responsibilities of global public health and health security to other international structures, most notably various organs of the United Nations [36]. In September 2014, the UN authorized the first-ever UN emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER), and thus became the central actor charged with mobilizing and coordinating resources across UN agencies, multiple states, and other partners working to stop EVD. UNMEER was established as a temporary measure to provide immediate financial, human resource, and logistic support for affected countries with the primary objectives of stopping the outbreak, treating the infected, ensuring access to essential services, creating stability, and preventing further escalation [56]. However, UNMEER’s participation has not been without criticism. In fact, reports by panels/commissions have noted that while UNMEER brought high-level political and financial support, coordination of the crisis became more difficult during its tenure in affected countries [38, 39]. Nevertheless, UNMEER’s creation brings a new dimension to global health governance as it is the first apparatus constructed to provide a singular UN system-wide approach in order to establish unity in combating a public health emergency. In addition to UNMEER, David Nabarro (who acted as Chair of the WHO Advisory Group and who is also a current candidate for the new WHO DG) was appointed as the UN Secretary-General's Special Envoy on Ebola in August 2014, for the purpose of providing strategic and policy direction to improve the international response to EVD.

UNMEER’s creation, though not viewed as entirely successful, may serve as a precursor for what future global health governance structures could look like in the absence of an adequately strengthened and empowered WHO. Hints of this potential governance “shift” manifested in different panel recommendations, with all panels calling for some form of increased involvement by the larger UN system. Specifically, the Interim Panel called for the appointment of a Special Representative of the Secretary-General or a UN Special Envoy for high-level global health threats, but stopped short of recommending the establishment of a full UN mission [57]. The Harvard-LSHTM report concluded that an independent UN Accountability Commission was needed to assess worldwide responses to outbreaks and also recommended the creation of a Global Health Committee as part of the UN Security Council [39]. The CGHRF called for better communication and collaboration mechanisms between WHO and the UN (including an escalation process to transfer control of emergencies from WHO to the UN Secretary-General,) and also specified that the UN Secretary-General should lead in developing strategies for sustaining health system capacities in fragile/failed states, though it did not support the creation of a new UN entity [41]. The UN’s own Kikwete Panel specifically recommended the creation of a High-level Council on Global Public Health Crises housed within the General Assembly made up of 45–50 political representatives of member states in order to ensure political accountability and reform implementation [42]. Germany's Chancellor Angela Merkel’s keynote speech at 68th WHA was even more direct, stating that WHO cannot tackle Ebola or global health on its own, and that its cooperation with the broader UN system and World Bank is a critical component of any reform moving forward [58, 59].

Though calls for greater involvement by the UN in global health have accelerated following the EVD outbreak, recommendations for a permanent UN global health structure are not new. As early as 2012, this author specifically advocated for the formation of a UN Global Health Panel chaired by WHO, which could alternatively be housed within the UN Economic and Social Council (ECOSOC) - a central mechanism of the UN system that has been active in global health issues (including developing the UN Sustainable Development Goals) and is the principal UN organ coordinating work across its 14 specialized agencies [45]. ECOSOC represents an optimal space to establish cooperation, coordination, and policy coherence across the entire UN system, its technical agencies, and its respective stakeholder networks on key global health challenges, including health emergencies (see Fig. 1 for visualization of governance recommendations by the panels and the UN Global Health Panel recommendation) [45].

An ECOSOC UN Global Health Panel would meet many of the needs identified in post-EVD governance reform discussions, including acting as a permanent central body to coordinate global health efforts across the entire UN system (including alignment with the SDGs), allowing engagement with a broader array of stakeholders and creating a "safe space" for these interactions through its partnership initiatives and forums, and could be designed in a way that would afford it greater political visibility as well as increased accountability by having it report directly to the UN General Assembly [37, 45, 60‐62]. Similarly, the creation of a Global Health Committee contained within the UN Security Council - as recommended by the Harvard-LSHTM panel - could also elevate health emergencies to the highest levels of political attention and raise awareness among key decisionmakers. However, the highly political nature of the Security Council could also result in public health priorities being stymied by larger and more influential political, security, and core foreign policy dynamics, as has been the case in other health diplomacy outcomes [63‐65]. Further, the High-level Council proposed by the Kikwete Panel would not implicitly include important multistakeholder representation from international public health agencies, non-state actors, NGOs, civil society, and other health actors, instead relying upon the exclusive participation of member state political representatives.

More fundamentally, critical in assessing whether any UN global health apparatus will work as a central pillar in the future architecture of global health governance is defining the appropriate roles and responsibilities of WHO with respect to other UN institutions that are already actively participating in global health [60]. This is necessary in order to avoid duplication and ensure effective coordination, a challenge highlighted by the temporary and emergency nature of the UNMEER governance intervention during EVD. This would require focusing a proposed UN global health panel’s structure on galvanizing high-level political and financial attention to a health emergency/outbreak, while also creating a permanent policy and governance environment conducive to multistakeholder partnership building, coordination, and mobilization of resources that is beyond the scope of WHO’s current operational mandates and capacity.

However, this structure would also need to leverage the unique strengths of WHO, specifically allowing the embattled agency to focus on its indispensable role as the world’s chief technical health agency by imbuing it as the Chair of the proposed structure and having the newly established WHO Health Emergencies Programme take a leading role when addressing issues related to health emergencies and outbreask with panademic potential [45]. Though some may view a UN-based structure as usurping WHO’s credibility and leading to duplication, by positioning WHO as the chair of a UN Global Health Panel, such a structure could serve the dual role of reestablishing WHO’s relevance and strengthening its response capabilities [66‐68]. This would be accomplished by enabling WHO with high-level political representation and access to all the resources at the UN system’s disposal.

Through this structure, WHO could then establish clear and delineated roles for other actors when preparing for and responding to health emergencies. It could then act as both the primary coordination mechanism and provide technical support to other UN institutions, such as the World Bank, UN Development Programme, UNICEF, UNAIDS, UN Environmental Programme, UN Population Fund, UN Office of Drugs and Crime, Food and Agriculture Organization, many of whom were active participants in the fight against EVD [45]. The design of the structure should also leverage existing inter-agency structures already established between WHO, the UN and other health partners (including the Global Health Cluster and Inter-Agency Standing Committee that both focus on humanitarian and health issues.) [13]. In this sense, a UN global health panel apparatus could act as a hybrid multistakeholder global health body bringing together the respective organizational and partnership networks available between the UN system and WHO. This would enable more robust engagement with key civil society actors, NGOs, foundations, civil-military cooperation, and private sector actors that will be critical in the prevention, detection, and response to future health emergencies and potential pandemics.

Finally, by placing global health, health emergencies, and infectious disease governance at the top of the UN hierarchy, the opportunity to establish greater policy coherence across the entire landscape of global governance mandates and instruments could be better realized by a UN Global Health Panel. This includes ensuring that all member states, UN agencies, and non-state partners are aligned under SDG goals 3.b (supporting R&D for infectious diseases), 3.c (ensuring a sustainable health workforce in developing countries) and 3.d (strengthening capacity for risk reduction and management of global health risks), all factors critical in preventing and responding to infectious disease outbreaks. This in turn could translate to better funding, strengthening, and implementation of the IHR and the WHO R&D Blueprint, while also supporting wider adoption of the WHO Global Code of Practice on the International Recruitment of Health Personnel [69, 70]. Additionally, other global health governance mechanisms can also be championed at highest levels of political engagement, including proposed instruments such as the biomedical R&D treaty and the Framework Convention for Global Health, which could bolster the normative powers of WHO [29, 71, 72]. This could establish a strengthened global health governance system, a step that is needed to ensure that global health and infectious disease outbreaks are given their rightful priority in the echelons of foreign policy and international affairs.