By Andreas Vilhelmsson
When the Ebola virus disease epidemic hit West Africa in late 2013, nobody could imagine that just a year and a half later it will have caused more than 11,000 deaths and be declared a threat to international peace and security. The outbreak overwhelmed the world. Building on this experience, the World Health Organization (WHO) recently announced that it would create a new programme for health emergencies, uniting outbreak and emergency resources. Dr. Margaret Chan, the Director-General of the WHO, announced plans to complete these changes by the end of the year in her opening speech at the Sixty-eighth World Health Assembly. Chan is also calling for a new US$100 million contingency fund to finance the health emergency programme.
This announcement was a direct response to the harsh criticism of weak leadership the Organization received in the aftermath of the outbreak. Among other things, the WHO has faced criticism for the slow international response to the epidemic and a weak leadership overall. One of the strongest critical voices belonged to Médecins Sans Frontières (MSF) who referred to “a vacuum of leadership” in the WHO, leaving them to deal with the Ebola virus in West Africa almost single-handedly — a virus that WHO should have been fighting.
A fragmented budget
The global scale of the Ebola outbreak, argue Gostin and Friedman in a recent article in the Lancet, is the type of moment for which the WHO was created. But instead, the Ebola crisis revealed fragile national health systems and a fragmented global health response system, with WHO falling short of its leadership responsibilities.
But does this really come as a surprise?
Today, only 25 percent of WHO’s biennial programme budget comes from assessed contributions, while the remainder comes from voluntary funds that are largely restricted for purposes specified by donors. In the wake of the global financial crisis, the Organization has been forced to endure austerity cuts and most of its budget now depends on these voluntary contributions. The truth is that WHO is inadequately funded to deal with threats like Ebola.
And here is the catch with the WHO-proposed contingency fund. The call for US$100 million may sound good, but it will be financed by flexible voluntary contributions. Funding by flexible voluntary contributions raises concerns if it will actually raise the money needed in the end, or if it will falter under the obligatory promises donors make when they are in the spotlight. Competition for donor funds between the WHO Health Emergency Programme and other global commitments is a real possibility. For example, the COP21 climate summit in Paris in December is approaching, and the need for new donor pledges to reach a global climate deal. Despite the new health emergency programme, Ebola still risks becoming “yesterday’s news”.
The contingency fund will also be built on partnerships with other organizations, ranging from UN agencies or NGOs like MSF. Today, these different collaborative efforts are often formalized in a large number of public-private partnerships (PPPs). These partnerships may be formed by cooperation between the global health sector (e.g. WHO) and NGOs (e.g. MSF) in dealing with health emergencies like Ebola, but can also involve private organizations in an effort to raise large amounts of financial resources for a particular disease or cause (e.g. Gavi). In some cases, the latter kind of PPP can turn out to be problematic, and is sometimes quite accurately described as a double-edged sword.
Though many PPPs have the advantage of funding and can also be cost-effective, oftentimes, the private sector and public health sector have different priorities and implementation practices. Private sector involvement in international health may skew the global community’s prioritization of issues and interventions, which may be questionable from a public health perspective. An example would be the prioritization of communicable diseases like HIV/AIDS and malaria in the global health space, which lead to non-communicable diseases and the social determinants of health receiving less resources in spite of their heavy burden.
The importance of trust
The global health architecture is far more complex today than it was only 10-15 years ago. The bureaucratic complexity of the WHO may hamper the will of Member States to involve the Organization in global health projects, and many will instead try to bypass it. For example, it was recently announced that the United States and the African Union (AU) signed a Memorandum of Cooperation to support the establishment of an African Center for Disease Control (CDC) Unit with the help and technical expertise of the United States CDC. The Lancet notes that the press releases about this venture fail to mention any WHO involvement, something that could indicate a lack of confidence in WHO policy-making and implementation capacities.
I believe that public health is all about trust, and the WHO need to regain the trust of the international community. Gostin and Friedman see the tragic Ebola epidemic as a window of opportunity to build a robust, universal global health system, once and for all. They propose a new global health framework, with strong national systems at its foundation and an empowered WHO and well-coordinated funding supporting the health of member states. Achieving this system requires a change in the budget allocations concerning voluntary and assessed contributions, and a WHO with more budget control. An empowered WHO ought to have the capacity to be a guardian of global health, but this mission will require sufficient funding.
The bottom line is this. If we want to live in a world capable of dealing with global health emergencies, like SARS and Ebola, we need to pay for it. 2015 is a seminal year for global health, marking 70 years since World War II, and the WHO’s establishment, and new opportunities to achieve health for all under Sustainable Development Goal 3.2 (SDGs). Seven decades have passed, but we must not forgot why the WHO was set up in the first place:
“The health of all people is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.”
World Health Organization. Media Centre. Sixty-eight World Health Assembly opens in Geneva. [ONLINE] Available http://www.who.int/mediacentre/news/releases/2015/wha-18-may-2015/en/ [Accessed 18 May 2015]
WHO Director-General’s speech at the Sixty-eighth World Health Assembly
18 May 2015 [ONLINE] Available http://www.who.int/dg/speeches/2015/68th-wha/en/
[Accessed 21 May 2015]
Médecins Sans Frontières. Report. Pushed to the limit and beyond. A year into the largest ever Ebola outbreak 2015. Available http://www.msf.org/article/ebola-pushed-limit-and-beyond [Accessed 23 March 2015]
Gostin LO & Friedman EA (2015) A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex. Lancet 385:1902-1909.
World Health Organization. Sixty-eight World Health Assembly. Provincial agenda item 16.1. A68/25 [ONLINE] Available http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_25-en.pdf [Accessed 8 May 2015]
The Lancet (2015) The African CDC and WHO AFRO. Lancet 385:1592.
WHO. WHO Constitution. [ONLINE] Available http://whqlibdoc.who.int/hist/official_records/constitution.pdf [Accessed 18 May 2015]