The exception should become the rule in the World Health Organization

After the West African Ebola epidemic of 2014, hardly anyone contests that the World Health Organization (WHO) made fatal mistakes during the crisis. It reacted too late and did too little to contain the outbreak before it got out of control. And it once again exposed its deeply entrenched dysfunctions that make it so difficult for the organization to live up to its role as the central standard setter, coordinator and crisis manager in global health. First, the WHO’s dramatic budgetary situation, with a near-total dependence on voluntary funding, had lead to tragic cuts especially of personnel and funds for emergency responses. And the quasi-autonomy and politicization of its regional offices slowed down the WHO’s response to Ebola and created confusion for external collaborators. Ebola brought these flaws to the spotlight, right in the midst of an ongoing reform process, which officially was launched in 2011.

Reforms to strengthen the WHO’s emergency branch in the wake of the Ebola fiasco are already underway. The learning process started with a set of initial recommendations made at the 68^th World Health Assembly in May 2015, and has been continued with two further WHO-commissioned and several external evaluations that make further recommendations. The WHO Director-General Margaret Chan has already announced that she intends to implement the recommendations of the most recent first advisory report delivered by a panel chaired by David Nabarro. She and the WHO’s member states would also benefit from considering the very pertinent list of ten reform suggestions put forward by an external review panel convened by Harvard University and the London School of Hygiene and Tropical Medicine (LSHTM).

It is still too early to foresee whether the reforms will be rigorously implemented and whether they will suffice to prepare for future crises. Yet, what becomes already clear from the new reform dynamic is that the “emergency branch” of the WHO will get exactly the medicine that would be needed for the organization as a whole — a medicine that can make the WHO internally more centralized and externally more accountable. I will mention three key lessons.

A first lesson is that a functional WHO needs reliable funding. In order not to repeat the protracted and cumbersome fund-raising efforts at the head of Ebola 2014, the Harvard-LSHTM panel suggests that a strengthened WHO emergency unit command a “protected budget” in the form of a “revolving fund” that is readily available when the organization needs it. In almost the same words, the Nabarro report asks for “predictable ‘steady-state finance’ as well as prompt access to a reliable contingency fund.”

A second lesson is that to act coherently, the WHO needs to centralize its governance and reporting lines. In that vein, the WHO’s first advisory report basically suggests that in times of emergency, crisis managers should be enabled to bypass the regional offices. It lays out in much detail the “centralized” procedures through which a strong emergency program should rapidly access funds, activate partners, recruit staff and work directly with countries — and thus be exempted from “normal” bureaucratic politics in an organization whose extent of regionalization is unique in the United Nations system.

A third lesson is that good global health governance needs transparency. Given the intense public scrutiny and politicization of global health crises, the “emergency WHO” has already begun to learn this lesson. When the WHO for the first time used its emergency powers during the 2009 swine flu outbreak, its failure to do so transparently backfired and was soon corrected. The practice of keeping secret the names of emergency advisors — many of whom later turned out to have ties with the companies that benefited from the swine flu crisis — was not repeated after the much-criticized H1N1 “pandemic” alerts. The Harvard-LSHTM report goes further in this direction. It demands that instead of the director-general, a transparent standing emergency committee should be entitled to declare global health emergencies, and obliged to publish the minutes of its deliberations. It should be financed “purely through assessed contributions to protect against undue donor influence.”

In brief, the WHO should be properly resourced, protected against lobbyism, and held publicly accountable in order to be a reliable crisis manager. Yet how shall it safeguard global public health when the acute crises are over? How shall it set reliable standards or advise governments on policy priorities and long-term concerns such as the rational use of medicines? Bureaucratic infighting, the dependence on the short-term goodwill of donors, and intransparent governance structures are as harmful for the “normal” business of the WHO as they are for emergency politics. In fact, the wish to make “special” arrangements for the emergency branch of the organization only underlines that the “normal functioning” of the WHO is in itself an emergency.

The unchecked and politicized functioning of the regional offices has been criticized for decades. And it is equally clear that the WHO’s budgetary situation is not sustainable, if not outright absurd. The main share of this budget must be raised through voluntary contributions, which are paid on top of a minuscule core budget funded by assessed contributions (making up about a fourth of the total budget). In the present situation, the WHO director-general must reinvent herself as a saleswoman. Her job is to persuade donors during so-called ‘‘Financing Dialogues” that they pay for the not-so-fashionable (or profitable) holes in the organization’s program budget.

And finally, the WHO continues to fear transparency. In the ongoing negotiations about new and better regulations for its collaboration with private actors, the WHO secretariat has once again proven allergic to strict conflict of interest regulations. As global health activists have recently revealed, the WHO’s secretariat is fearful of being too restrictive or transparent when it comes to staff secondments, advice, or financial support received from the private sector. In the present condition, the WHO simply cannot afford to lose the goodwill of its donors and donor states. Unfortunately, it is unlikely that the organization will heed the excellent advice given in the tenth and final section of the Harvard-LSHTM report, which calls for an all-out governance reform. It rather seems that Ebola 2014 will not become the critical juncture that makes these reforms possible, but a crisis that cements the bifurcation into an emergency WHO and a normal state of emergency in the WHO.

Headline image: Ebola Virus Particles by NIAID. CC BY 2.0 via Flickr