WHO Must Reform Emergency Response, Adopt Unified Mechanism, Advisory Group Says

A report by an advisory group tasked with helping with the reform of the World Health Organization’s response to outbreaks and emergency situations calls for a unified response from all geographical levels of the organisation. The recommendations raised concern from some, but the WHO director general said she sees consensus.

During the first day of the WHO Executive Board meeting, taking place from 25-30 January, the Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies with Health and Humanitarian Consequences presented its second report [pdf], with recommendations.

The advisory group, which was established by WHO Director General Margaret Chan in July 2015, produced a first report [pdf] in November.

According to David Nabarro, chair of the advisory group, and United Nations Secretary-General’s Special Envoy on Ebola, presenting the report, WHO needs to be able to offer the best expertise in the world.

He underlined the importance of work at the local level. The report, he said, suggests establishing an organisation-wide programme on outbreaks and health emergencies, ensuring best practice across the organisation. It would have one line of accountability, one system for financing with the same budget everywhere, with adequate financing, and a completely new set of business processes. And it would involve staff with skills tailored to local situations and shown to be the best in the world, and one set of benchmarks, so that anywhere in the organisation the standards are the same.

However, he said, making one organisation-wide programme calls for a “profound transformation,” adding: “The world wants a new programme that is predictable and dependable.”

Nbarro stressed that the suggested change is not about centralisation, but decentralisation done in a way that it is entirely predictable and standardised across the organisation.

There is the need to have an “absolute clarity on who is responsible for what,” he said, otherwise it is very difficult for governments and WHO partners to know where to get advice and work out what needs to be done.

“It is the fundamental challenge that WHO has been facing in emergencies and outbreak operations for years,” he said.

It is the uncertainty about where the authority lies and who is responsible for decision-making “that makes WHO, the world’s premium health organisation, difficult to work with in outbreaks and emergencies,” he added.

Anxiety from Member States, in Organisation

The set of recommendations provided by the advisory group has provoked anxiety among some member states, and among some people in the organisation, he said. However, as a personal note, he said WHO is absolutely essential in outbreaks and emergencies.

“There is no other organisation than can do the job that WHO does,” said Nabarro, adding member states “have a really key role to play now to make sure that we get it right as the reform is taken forward by the director general.”

“Please have the courage to make this one come out right,” he pleaded. He called for WHO members to focus on what needs to be done “rather than being distracted by what this might mean for the responsibilities and authorities of different individuals within the organisation.”

Regional Offices Call for Resources, Underline Role

Kuwait, for the Regional Office for the Eastern Mediterranean (EMRO), said it is important to have the resources to ensure that WHO will operate in unison. The delegate underlined the importance of the link between the functionality of regional and country offices to avoid duplication and a clash of responsibility.

Liberia, for the Regional Office for Africa (AFRO), said the role of WHO headquarters and the regional and national offices should be clearly defined in case of severe emergencies. South Africa underlined the need for countries to have a strong and resilient health system.

Jordan stressed the fact that regional offices are well placed to respond to emergencies and crisis and that a bottom-up approach is desirable. The representative warned against possible duplication brought on by the new mechanism. Zimbabwe said there is a need to understand the role for regional offices and understand how to get from the present organisation to the unified programme.

India remarked that WHO can supplement but not supplant national efforts, and work already done at the three levels of the organisation should not be duplicated. The Indian representative said a clear hierarchy should be established between regional directors and the director general. He also stressed the importance of the timely access to drugs and vaccines at the country level.

Thailand asked that the director general further develop a blueprint to improve research and development preparedness for major infectious disease threats. The Thai representative remarked that Ebola had been around for 40 years but the international community and vaccine industry had failed to provide an effective vaccine, “because affected countries are too poor to purchase vaccines.”

Malta, for the European Union, expressed concern that the report [pdf] by the director general on the issue does not contain a clear enough programme with a unified budget. Neither does it give an “ambitious timeline, more emphasis on strong partnerships, importance of independent risk assessment, accountability, and clear lines of authority.” The EU called for the director general to follow the lines of authority as recommended by the advisory group, according to its statement.

The United States underlined the importance of a single, unified emergency programme and chain of accountability. In this unified programme, the US sees an essential role of regional and country offices, the representative said.

Switzerland advocated for the unified programme, underlining the fact that this would not bypass regional and national directors.

On 26 January, Nabarro said the problem is: “Should there be a single organisational-wide programme with a single authority, and a single set of procedures, and a single dedicated workforce, with predictable benchmarks that can be tested, or is the problem just the shortage of funds? And should there be more resources put into the countries, strengthening of the regional offices with decentralisation increased with the fundamental action at the regional level with each region with its own strong emergency programme with headquarters providing bits of support when requested? Which way? And frankly, there is a split and this was identified.”

However, he warned that if WHO members come up with something that does not pass the test of political leaders and experts in disaster management, “the money won’t come.”

Director General Confident, Sees Consensus

In response to the countries criticising her report, Chan said the report of the advisory group was received in the days before the EB and her own report should be seen as work in progress, referring to her report to the EB on the follow-up to the Special Session of the Executive Board on the Ebola Emergency (resolution EBSS3.R1) and the Sixty-eighth World Health Assembly (decision WHA68(10)).

Speaking on behalf of the regional directors, she said, “We welcome the Advisory Group’s concrete recommendations and will take prompt action to implement them.” “We hear more consensus than you think,” she added.

“You want a strong WHO,” particularly in emergency response to health crises? Chan asked. “We will do that.” She added that the WHO fully agrees on a single response programme, rather than seven (six regional offices and headquarters).

“You want us to provide clarity and responsibilities” for the three levels of WHO and avoid duplication and delay in the response? “We will do that,” she asserted. A clear line of responsibility and authority with the director general in charge? “We will do that,” she said.

The WHO will develop a roadmap and prioritise action and timeline. The secretariat is fully committed to transform the organisation to lead in health crisis for the interest of the people, said Chan.

The report by the Advisory Group was noted by the EB.