World Health Organization and emergency health: if not now, when?

What is actually wrong with WHO?

The Ebola epidemic was the culmination of multiple instances, mainly undocumented, of WHO underperformance in crises. The box summarises recent examples, partially based on our direct observations. These examples delineate six stand-out problems, as discussed below.

Prioritisation of political over technical considerations

WHO’s emergency response framework 32 sets guidelines for managing new emergencies. However, its current version is arguably too focused on process rather than action and does not attribute authority to WHO when governments or other bodies are responding inappropriately. WHO’s leadership of the Global Health Cluster provides a legitimate avenue for establishing sector leadership and coordination, though this approach relies on agencies’ voluntary participation. The International Health Regulations provide instruments to deal with the inter-country dimensions of large epidemics, though they ascribe little authority to WHO to enforce technical recommendations. Improvements to the regulations, including earlier triggers for smaller outbreaks and incentives for countries to report and comply, have been recommended,20 and the regulations are under review.

Constitutionally, WHO is governed by member states, with senior managers at headquarters, regional, and country offices appointed with the approval of national ministers of health.9 33 34 While preventing hegemony by powerful stakeholders, this political dependency has degenerated into a culture that rewards protocol over substance; caution over courage; hierarchy over competence; conservatism in estimating problems; and obfuscation of evidence that might challenge relations with governments or donors. Public health considerations are often sidelined,35 and in high stakes situations such as Ebola virus disease and severe acute respiratory syndrome (SARS) epidemics, or state based conflict, political conditioning of WHO’s response at country level often drives decision making at higher levels of the organisation. This is a reversal of the power structure required to respond to complex emergencies and obstructs WHO’s role of brokering data collection, analysis, and dissemination.

WHO’s tendency to maintain the status quo36 is not exceptional: many organisations become subservient to their own bureaucracy and political pressures. WHO, however, stands out for its inability to overcome these obstacles in times of crisis.

Non-meritocratic human resources approach, with little reference to crisis response competencies

WHO replaced all three country representatives in Guinea, Liberia, and Sierra Leone as the Ebola response was scaled up, indicating that key staff who should kickstart the organisation’s emergency responses in the field are often unsuited.37 WHO does not necessarily reward or promote based on merit, and staff performance management is constrained by the often short duration of staff contracts. Many senior positions are filled through informal political appointments.

Moreover, technical, managerial, and soft leadership competencies are not sufficiently considered during hiring and professional development of staff who oversee the response to crises (such as country representatives).36 Internal bureaucracy required to hire staff, or second people from other agencies, also curtails emergency responses.

Aloofness from civil society partners and neglect of sector coordination and leadership functions

WHO has traditionally prioritised its relationship with governments over that with civil society (non-governmental organisations, academic groups, professional associations), and headquarter, regional, and country staff with roles in managing crises (particularly epidemics) often have insufficient understanding of the international humanitarian architecture.4 19 There is an unresolved tension between WHO’s conflicting mandates of supporting governments, and coordinating and leading the health sector during crises, particularly when governments are a party to conflict or obstruct the response.

Three areas have suffered from this neglect. Firstly, WHO has not sufficiently taken up sector leadership and coordination and is often perceived by non-governmental partners as a conduit for political agendas. WHO’s leadership of the Global Health Cluster (set up in 2005) has been inadequate. Until 2014, only one headquarter staff member was dedicated to the cluster secretariat, and most of the 24 activated field clusters are inadequately staffed. Key areas of work (cluster coordinator training, roll-out of epidemiology and information management tools, raising cluster funding) have progressed slowly. Other UN agencies (Unicef, the World Food Programme, UNHCR) are more amenable to collaboration with civic society and have been more successful at leading and coordinating field operations. For example, clinical management of rape has primarily been tackled by the Global Protection Cluster, led by UNHCR, despite this being a health intervention.

Secondly, WHO has not played a major role in developing standards and policy for crises, though this normative function is arguably its principal strength in other areas of work. Such normative work should include developing a stronger evidence base for the health related technical standards of Sphere (the most widely used guidance for humanitarian interventions)38 and other guidelines, which currently mostly reflect expert opinion. Similar problems exist with the “process standards” setting out expected actions at different stages of an emergency, including preparedness and recovery or mitigation. This role has partly been filled by other agencies, particularly Médecins Sans Frontières and the US Centers for Disease Control and Prevention. Building the requisite capacity of emergency response agencies and staff at the scale required to tackle multiple emergencies at once, however, has been globally neglected.

Thirdly, WHO has been timid in promoting health standards and quality control of crisis responses, though it has no formal enforcing authority. The Sphere project and other initiatives have tried to shift emergency response from a philanthropic (whereby any charitable act is helpful and not to be questioned) to a rights based model, but this transformation is incomplete. There is no formal professional certification of individuals or organisations and little recourse for people who are denied access to or provided with inappropriate services. As an exception, the current WHO emergency medical teams project to certify, standardise, and coordinate international medical groups deploying into natural disasters has enhanced the quality of recent surgical responses in Nepal and the Philippines. This project merits consideration as a model for ensuring that agencies and individuals do not operate without regulation, oversight, or enforcement.

Lack of internal and external accountability

Accountability to beneficiaries is increasingly emphasised in humanitarian practice.39 WHO, however, sees itself as accountable to and providing technical assistance to governments, even those with dubious legitimacy.4 Although WHO’s performance is overseen by member states and, specifically, its executive board, these governance arrangements do not enable in-depth monitoring of crisis performance; this would require objective metrics and systematic evaluations by independent experts.

Whereas most humanitarian agencies have internal monitoring and evaluation teams and frameworks, WHO has limited mechanisms or incentives for evaluating itself objectively and tackling underperformance. Its headquarters is institutionally averse to effecting change in the regions despite disbursing general funds to them,40 possibly because regional offices can block central influence on countries.41 Generally, WHO’s management has discouraged transparency and admission of fault, exemplified in May 2015 by the self censorship of an unusually candid statement of responsibilities for the Ebola disaster, which was replaced by a heavily sanitised version within hours of publication.42 This tendency undermines opportunities for learning that are fundamental for self improvement. Admittedly, external observers, including the media, have not always generated constructive, actionable criticism of WHO.

Problems with current structure

Over the past decade WHO headquarters, particularly its humanitarian and epidemic divisions, has experienced ongoing restructure and reform33 43 44 with no observable leap in performance. Nevertheless, the current split between teams working on epidemic and pandemic control and those focusing on armed conflicts and disasters (which are better linked to the wider humanitarian architecture) is widely seen as unhelpful and is being removed at headquarters through the creation of a single outbreaks and health emergencies division.13 16 45 Moreover, WHO’s crisis response structure differs in the headquarters, regions, and countries, precluding a fully unified approach.

Insufficient flexible funding for crisis functions

The reduction of its core, unrestricted funding, cited by WHO as a reason for its low performance during the Ebola epidemic, reflects donors’ increasingly vertical approach but also low donor confidence in WHO’s ability to manage funds responsibly.33 46 Shrinking core funding and staff cuts have impeded strategic planning and timely response.4 13 Instead of engaging with WHO to demand greater performance in crises in exchange for adequate, flexible funding, donors have broadly withdrawn interest and support, or sponsored non-WHO solutions like UNAIDS and the Global Fund for AIDS, Tuberculosis and Malaria.

Six proposals for reform

There is no single recipe for improvement nor a clear encouraging precedent. The past two decades have seen several ineffective attempts at WHO reform.43 44 47 48 We believe that any reform will fall short of desirable outcomes unless the problems listed above are explicitly tackled,12 guided by a clear plan with objectives and expected outcomes at country, regional, and headquarters level. Broad measures, with which we largely concur, have already been recommended by the executive board,17 WHO’s Ebola interim assessment panel,14 and others.11 13 16 19 Aside from restructuring WHO headquarters, the current reform process seems to be focusing on topics (the financing of a $100m emergency fund; the establishment of a global health emergency workforce) that are secondary to more fundamental changes.

The table⇓ lays out six proposals for reforming WHO in relation to the critical problems identified above. Aspects of these proposals would doubtlessly encounter resistance and carry transactional costs, with a foreseeable period of turmoil. However, a conservative, more cosmetic approach would probably leave WHO at risk of even further reputational damage and dismemberment13 and populations exposed to substandard responses.

Incisive reforms now may be less expensive in absolute terms than maintaining the status quo (particularly considering the cost of poorly controlled emergencies such as Ebola, and the inefficiency of multiple WHO-like global health institutions). Indeed, we argue that the $100m health emergency fund (only about 2% of total humanitarian funding for Ebola alone in west Africa as of August 201549) does not reflect a real need and is unlikely to be spent efficiently; instead funds should be earmarked for refreshing staffing of critical posts and creating a pool of technical experts within WHO and partner agencies to fill leadership and coordination roles in emergencies, backed up by a well resourced professional development plan.

Not all parts of WHO’s crisis response are dysfunctional. The Pan-American Health Organization (PAHO), also known as WHO’s Americas Regional Office (AMRO), has a tradition of effective response to disasters, facilitated by more streamlined governance. WHO’s Western Pacific Regional Office (WPRO) has overseen substantive responses to recent disasters in the Philippines. Both these regional offices have supported countries’ emergency preparedness. WHO does groundbreaking work on mental health in emergencies, has recently established a functional cholera vaccine stockpile, and its emergency medical team project appears to be succeeding. Numerous experienced specialists in epidemics and other hazards work across the organisation. Clearly, a nuanced approach is needed to preserve what works well. Our proposals are not aimed at strengthening regional and country offices other than through professional development. Transferring authority and resources back to these offices is a desirable next stage in reform but will require major investments to improve their governance and management.

Governance of WHO and its reform

While the appointment of an external advisory body is welcome, WHO needs to go further in establishing transparency and oversight of the reform process. We propose that an external, independent governance committee be established for the new all hazards, outbreaks, and health emergencies division, composed primarily of people with minimal institutional allegiances (unlike the current advisory committee) and strong expertise in public health in emergencies or organisational management. This committee could be modelled on the independent monitoring board of the Global Polio Eradication Initiative, credited with improving oversight and accountability for that programme.50 It should independently appraise and validate WHO’s reform proposals. A work plan with clear milestones should be agreed, containing conditions for release of further funding and, if reform falls greatly short of commitments, the option of entrusting crisis related functions to a new entity outside of WHO, with WHO contributing in a diminished capacity. The external committee should provide ongoing strategic management of the all hazards division (table), thereby safeguarding WHO from internal reticence to change.

As reform moves forward, WHO’s main influencers—that is, its member states and principal donors—need to revise their relationship with the organisation, investing more resources in effective, real time governance and performance evaluation while simultaneously releasing proportionally more unrestricted funding to the organisation and empowering WHO’s managers to focus on evidence based crisis responses, not political relations, as recommended by the Harvard-LSHTM panel.13 A constitutional change, reducing WHO’s dependency on member states or allowing WHO in specific crisis situations to report solely to the UN, may be required to enshrine such a shift.

Similarly, civil society agencies should show greater willingness to engage with WHO and coordination mechanisms like the Global Health Cluster, freeing up resources to bolster WHO’s staffing. In turn, greater involvement of civil society should be seen as an indicator of improved WHO performance.

Conclusion

In 1994, ineffective coordination and delayed response to the influx of about one million Rwandan refugees into camps in Tanzania and the Democratic Republic of the Congo contributed to some of the highest death rates ever measured in humanitarian settings.51 This disaster resulted in historic initiatives to professionalise the humanitarian sector, including the Sphere standards.38 Two decades later, the failure to control the Ebola epidemic in its early manageable phase may be a watershed of comparable importance.

The Ebola response has highlighted the need for many agencies and governments to urgently upgrade their capability to intervene in all types of crises. However, such improvements will struggle to attain their potential if the world’s coordinating and technical leadership body remains unchanged. Indeed, if WHO cannot be reformed to allow it to occupy this pre-eminent position, some other multilateral entity must be allowed to assume it.

We believe that an effective, empowered WHO is a far better solution for global health governance, and for public health coordination and leadership in emergencies, than a multiplicity of partly overlapping entities, not all recognised by governments and at greater risk of becoming subservient to the most powerful governments and donors. To become the world’s chief healer in times of crisis, WHO needs to consent to major surgery. The thousands dead because of the uncontained Ebola epidemic in west Africa stand silent witness to the human cost of delayed, politically constrained use of available public health data, coordination, and means of response. A radical reform of WHO cannot be delayed any further.