from The Internationalist, International Institutions and Global Governance Program and Global Health Program

The Health of Nations: The WHO’s Moment of Truth

May 21, 2015

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Blog posts represent the views of CFR fellows and staff and not those of CFR, which takes no institutional positions.

Coauthored with Daniel Chardell, research associate in the International Institutions and Global Governance program at the Council on Foreign Relations.

The Ebola outbreak in West Africa underscored how vulnerable the world has become to infectious disease—and how vital it is to invest in global health security. Not since the H1N1 pandemic of 2009 had an epidemic garnered so much attention—and inspired so much fear—worldwide. But this window is closing fast. As Ebola has waned in West Africa, so has the political momentum for reforming the World Health Organization (WHO). The World Health Assembly (WHA), which opened Monday in Geneva, offers what may be the last chance to restore the badly tarnished credibility of the WHO and preserve its central role in pandemic preparedness and response.

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On Monday, the WHO’s 196 member states convened for the sixty-eighth session of the WHA. As the WHO’s governing body, the WHA normally considers minutiae of a technical nature; its proceedings are rarely newsworthy. But this year’s session will have far-reaching implications, including for the future of the WHO itself.

The WHO was in a precarious position before Ebola appeared in West Africa. But its bungled response to last year’s outbreak offered definitive proof to critics—including in the U.S. government—that the organization is not fit to manage public health emergencies of international concern, or PHEICs. This week’s assembly offers the WHO a last chance to commit to genuine reforms, and, by extension, reaffirm its leadership role in responding to such emergencies. If it fails to learn from past mistakes, it will be sidelined by alternative global health institutions.

The WHA’s deliberations will be informed by the preliminary findings of an independent panel reviewing the WHO’s dismal performance during the Ebola outbreak, released on May 8. That interim assessment attributes the WHO’s weak showing to multiple shortcomings, among them a weak chain of command, lack of accountability, poor coordination, crippling budget cuts, and indecisive senior leadership. The report also criticizes the WHO’s failure to cultivate relationships with other UN agencies, the private sector, and nongovernmental organizations—all of which proved vital to finally curbing the outbreak. “At present,” the panel concludes, the “WHO does not have the operational capacity or culture to deliver a full emergency public health response.”

However, rather than transferring the WHO’s responsibilities for emergency response to another agency (as some have suggested), the panel recommends that the WHA invest in WHO operational capabilities, by approving a new global health emergency workforce capable of rapid deployment to outbreak zones, as well as a $100 million contingency fund from which the WHO could draw in the case of a public health emergency of international concern.

For WHO watchers, the interim report elicits a sense of déjà vu. Four years ago, a committee charged with reviewing the WHO’s response to the H1N1 pandemic reached identical conclusions: “The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency,” the committee determined. The proposed solution? That the WHO establish a cadre of emergency health workers and a $100 million contingency fund. The WHO not only ignored the committee’s recommendations but took steps counter to its warnings, making deeper cuts to its emergency response capacity.

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To be fair, the fault does not lie entirely with the WHO. At the insistence of the United States and other powerful countries, the WHO since the 1980s has maintained a policy of zero nominal growth in annual member dues. Meanwhile, voluntary contributions—which individual donors can earmark for preferred projects—have surged as a proportion of its overall budget. The predictable result is that the WHO’s agenda is increasingly shaped by donor interests, such as the prevention and treatment of noncommunicable diseases, over broader public health capacity-building.

Meanwhile, a host of competing international institutions have entered the scene. From the Global Alliance for Vaccines and Immunizations (GAVI) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to powerhouse philanthropic organizations like the Bill and Melinda Gates Foundation, the WHO has increasingly found itself competing with a diverse range of new, more flexible, and better funded alternatives. Even before the Ebola outbreak, in February 2014, the Obama administration launched the Global Health Security Agenda (GHSA), a coalition of forty-four countries that aims to bolster the capacities of developing countries for epidemic response, including by boosting investment in public health infrastructure. The WHO participates in the GHSA, but it is clear to all that Washington holds the reins. The U.S. readiness to bypass the WHO was also on display last month, when the Obama administration and the African Union formalized the establishment of an African Centers for Disease Control, based on the U.S. CDC.

One devastating impact of WHO’s institutional weakness has been to undermine implementation of the International Health Regulations (IHR). First put into place nearly fifty years ago and revised in 2005 in the wake of the SARS pandemic, the IHR constitute the most important international legal regime to combat infectious disease. They require all countries to establish minimum core capacities to prevent, detect, and respond to outbreaks, and to notify the WHO of any events that constitute a public health emergency of international concern within their territories.

The Ebola outbreak underscored just how far WHO member states are from following through on these commitments—and how little leverage the organization has to ensure that they fulfil their obligations. There is no real accountability. Rather, national governments simply self-assess their own progress toward implementation. The results have been predictable. The initial June 2012 deadline for states to come into full compliance with the IHR has since been extended twice. And a quarter of all countries have failed entirely to report their progress to the WHO

WHO member states have violated the IHR in more blatant ways, too. The regulations insist that any national steps to contain the cross-border spread of disease must be “commensurate with and restricted to public health risks, and… avoid unnecessary interference with international traffic and trade.” In the panic of the Ebola outbreak, however, many countries imposed travel and trade restrictions that lacked any basis in science or endorsement by the WHO. Beyond being ineffective, even counterproductive, in combatting epidemics, such steps create a disincentive for affected states to declare public health emergencies in the first place, since doing so could result in an economically devastating quarantine of their countries. In the case of Ebola, alarmist foreign responses accentuated the plight of Liberia, Sierra Leone, and Guinea, whose economies are in shambles.

The Geneva meetings of the WHA offer WHO a last opportunity to reassert its former primacy as the lead agency for global health security. During the assembly, WHO member states are expected to endorse the creation of the proposed contingency fund and global health emergency workforce. This constitutes progress, to be sure. But these new initiatives do not begin to address the flaws of the IHR, to say nothing of boosting long-term investment in the public health infrastructure of low- and middle-income countries. Meaningful reform will require the WHO to show that it is capable of strengthening the accountability of its own regional and country offices to WHO headquarters in Geneva, developing stronger relationships with nongovernmental organizations and the private sector, and redoubling investment in outbreak surveillance and response units. But the onus of reform also lies equally with member states, which will have to make tough decisions about whether the WHO should be granted the power to impose sanctions on states that flout their responsibilities under the IHR, including by imposing unnecessary travel and trade restrictions.

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