Improving International Governance for Global Health Emergencies: Lessons from the Ebola crisis | Oxfam | Influenza A Virus Subtype H5 N1

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  OXFAM DISCUSSION PAPER JANUARY 2015   IMPROVING INTERNATIONAL GOVERNANCE FOR GLOBAL HEALTH EMERGENCIES: LESSONS FROM THE EBOLA CRISIS Oxfam Discussion Papers   Oxfam Discussion Papers are written to contribute to public debate and to invite feedback on development and humanit arian policy issues. They are ’work in progress’ documents, and do not necessarily constitute final publications or reflect Oxfam policy positions. The views and recommendations expressed are those of the author and not necessarily those of Oxfam. For more information, or to comment on this paper, email  2 LOOKING BACK The 2014  – 15 Ebola outbreak in West Africa has demonstrated again the urgent need for strong leadership and coordination when responding to global health emergencies. The outbreak started in Guinea during December 2013, but cases soon began to spread to neighbouring countries Liberia and Sierra Leone. Despite 25 previous outbreaks of Ebola being successfully contained, this time the disease spread from rural to urban locations and crossed borders, becoming a global threat  –  an unprecedented situation.  All actors in the Ebola crisis appreciate that this has been a challenging response. We are all in uncharted waters. Many agencies (including Oxfam) have struggled to identify and establish their role in the process, and therefore meet the needs of the people within this new landscape of a widespread, infectious, deadly disease in developing countries. We must learn lessons from this unprecedented outbreak, which will require a critical perspective. The World Health Organization (WHO) The WHO, a specialized agency of the UN, is responsible for leadership and coordination of global public health and health security. It is therefore central to responding to global health emergencies, such as the Ebola crisis. In the case of the current Ebola outbreak in West Africa, WHO was not notified of the outbreak by national authorities until March 2014. The WHO Regional Office for Africa (AFRO), charged with responding, failed to recognise the regional and global threat. Not until 8  August 2014 did WHO declare an international emergency that in turn activated a UN response through the UN Mission for Ebola Emergency Response (UNMEER). WHO’s Director  -General, Dr Chan, has acknowledged that WHO’s  response was slow, and indicated that a full enquiry will be conducted once the outbreak is under control. Regardless of the outcome of this investigation, it is thought that pre- existing weaknesses contributed to WHO’s failure to swiftly and successfully handle the situation, as it had done previously with other global health emergencies (e.g. SARS). These include: Funding:  WHO is an organization under strain due to severe longstanding financial difficulties. While member states demand more from WHO, this is not matched by sufficient funding. Their income is organized in a complex and unsatisfactory manner. For example, voluntary contributions can be made by donors to fulfil their own priorities  –  while the core work of the organization is chronically starved of resources. V oluntary funds outweigh WHO’s regular budget in a proportion of 80:20, leaving a disposable budget that is both inadequate and skewed towards specific priorities of donors. It is also important to note that WHO ’s  budget is only one-third of that of the budget of the US Centers for Disease Control and Prevention (CDC) , even though WHO’s remit is global. Staff and priorities:  Funding challenges have clearly led to difficult decisions being made on prioritization. Cuts to WHO’s emer  gency response capability, proposed by the Secretariat, were approved by the Executive Board, indicating that the Board is not prioritizing this area. As a consequence, many of its seasoned experts, including those with relevant knowledge of communicable diseases and surveillance, left the organization. In order to fulfill WHO’s commitments, remaining staff based in the Geneva headquarters have been unacceptably overworked and have had to juggle inadequate budgets between competing essential (core) functions. Lack of leadership at Geneva and regional level:  Both the regional office and Geneva headquarters have been criticized for a slow response and lack of leadership. The regions elect their own directors through regional boards, have considerable autonomy, and patronage and politics play a role in appointments. In the case of the Ebola response, responsibilities may have fallen between the centre and the region. Reform:  A process of root and branch reform was initiated by Dr Chan four years ago, in response to the financial crisis, to correct these weaknesses. The reform is still not complete. While clearly the leadership of WHO needs to take responsibility for these shortcomings, so do WHO’s Executive Board and UN Member States as well, who failed to provide active, effective stewardship.  3 Other organizations   Please note that this section only contains a brief summary of the most urgent issues. Beyond MSF, few organizations have operated consistently well in the West Africa Ebola response. Lessons need to be learned across the board. This is also true of Oxfam. As a non-medical organization, it took some time to establish how Oxfam's expertise could be best applied in the Ebola crisis. With hindsight, we got some decisions wrong and could have deployed specialist staff sooner to the Ebola- affected region. In line with Oxfam’s commitment to transparency and accountability, a full evaluation of Oxfam performance will be undertaken, made public and used as learning for the future. It may be appropriate to develop guidelines to establish when and how non-medical or non-health focused organizations should play a role in global health emergencies. In the absence of guidelines, non-medical organizations may contribute too late and only after health agencies have become overwhelmed. The role of the UN needs to be considered. Setting up a new organization, UNMEER, when faced with an unprecedented and highly time-critical crisis contradicts good practice in crisis management. The Office for the Coordination of Humanitarian Affairs (OCHA) could have also played a key role, and should have been more forward-thinking. Despite wanting to support UNMEER, they perhaps took too much of a ‘ wait and see ’  approach. Lessons from previous emergencies were not applied, and many systems were set up from scratch when this was not necessary. From a donor perspective, the US, UK and France provided leadership in Liberia, Sierra Leone and Guinea respectively. This approach should be reviewed in terms of its post-colonial symbolism and its effectiveness. Many governments have not honoured their pledge and prioritized obligations regarding the International Health Regulations (IHR). These regulations were agreed in 2005 to prevent national public health emergencies from becoming international crises. Outlined requirements should have been implemented by 2012, but in most developing countries this has not happened. A lack of funding, technical capacity and strong leadership from both governments and donors have contributed to this. There has been a suggestion that funding for national health systems has suffered due to policies from international financial institutions (IFIs). 1   LOOKING FORWARD There have been multiple failures in the Ebola response in West Africa, by both WHO and other agencies. These failures have left many people vulnerable. An improved system is required, both in terms of dealing with future Ebola outbreaks (experts suggest this will not be the last in West Africa), as well as other communicable diseases. To ensure a better international response to future epidemics in developing countries, we need to learn lessons from the current crisis. So the question now shifts; h ow can we protect people’s health and prevent disease outbreaks  from becoming epidemics? In particular, there is a clear need for: clear leadership on policy and technical issues; effective standing operational capacity to monitor and prepare for outbreaks; surge capacity to lead and resource an emergency response. These are fundamental requirements that are not currently in place. The debate is ongoing regarding the architecture required to meet these needs. WHO is the mandated UN agency for international health, with specific responsibilities for leadership, oversight of health security and coordination of international responses. 2  It is however a technical agency, without operational capacity to respond. To grow this capacity would be a long and expensive process. WHO relies on providing direct support to national governments to implement its technical advice. This worked successfully in China in relation to SARS, as well as in Uganda and DRC for Ebola. However, most low-income developing countries need far more technical support to deal with outbreaks due to their lack of capacity, particularly human resources. There have apparently been some discussions 3  on establishing a new ‘ first responder  ’  UN agency that would provide emergency operational assistance in humanitarian crises, by rapidly deploying  4 trained personnel, equipment and supplies. While an enhanced rapid response would be beneficial, a new agency would likely be subject to the same vagaries of institutional funding and Member State interests in delivering its mandate, leading to duplication. It may be more useful to first ensure that existing mandates are respected, roles and responsibilities are clear, and organizations are capable and resourced to fulfil their mandates. WHO has published a report 4   detailing the development of WHO’s capacity to prepare for and respond to future epidemics, to be discussed at a special session of the WHO Executive Board meeting, 25 January 2015. This offers a helpful perspective and demonstrates WHO’s resolve on this issue. But perspectives need to be sought from beyond WHO. Ensuring a better international response in times of global health emergency cannot be solved solely through strengthening WHO processes, the time needs to be taken for lessons learned from across the response to be collated. The Ebola response in West Africa has been extremely challenging and it is important that we confront our collective performance head on. We must accept our failings, learn from them and continually seek to improve our response systems. Oxfam is about to start an evaluation of its own work, and we know other NGOs involved in the response are doing the same. However, we are not currently seeing this honesty and willingness to learn from the UN. Most recently, the UN has published two reports  –  from UNMEER and WHO 5    –  that reflect on the response to date and map out future directions. They have been seeking to build a narrative around the Ebola response that is clear on the positives, but not on the negatives. Building accountability around this response is key for the future. Pointing fingers and the blame is not helpful, but equally nor is failing to confront the difficulties, and thus failing to learn. RECOMMENDATIONS To maximise the lessons learned, an independent   evaluation  is needed into the Ebola response, including, but going beyond WHO’s role.  This would perhaps be best served by an independent team of experts drawn from both humanitarian and health fields, ensuring an appropriate balance of perspectives. Such an investigation would include a clear evaluation and assessment of the factors that have hindered the speed and effectiveness of the current response, and would outline appropriate steps towards improving timeliness and the impact of future responses. To ensure that this enables the international community to develop an effective system that can support all health emergencies, the independent evaluation should also review: The global health response in other emergencies (e.g. Afghanistan, Syria and South Sudan). Progress against the major exercise on pandemic preparedness in 2010, led by David Nabarro. The World Bank and UN report 6  looked back to Severe Acute Respiratory Syndrome (SARS, 2003), H5N1 (‘bird flu’, 2003 onwards)   and H1N1 (‘swine flu’, 2009) and proposed three streams  of work: (a) prevention and control of Highly Pathogenic Avian Influenza, (b) adoption of One Health approaches, and (c) readiness for response to influenza pandemics. Progress against the report 7  of the International Health Regulations Review Committee in 2011, that assessed a) the functioning of the International Health Regulations (2005), b) the global response to the pandemic H1N1 (including the role of WHO) and c) identified lessons for strengthening preparedness and response for future pandemics and public health emergencies. Perhaps lessons could also be learned from the sector’s Humanitarian  Reform process that began in 2005. There was recognition at that time that humanitarian response was not always as timely and effective as it could be. The Emergency Response Coordinator, Jan Egeland, therefore commissioned a bottom-up review, which was taken forward into the Reform Agenda. This led to concrete changes, including development of the Cluster System and creation of the Central Emergency Response Fund (CERF). While neither a perfect process nor outcome, this has substantially strengthened humanitarian response.
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