The Ebola epidemic will take hundreds of thousands of lives if the current trajectory is not reversed. Fear has gripped the most affected countries: Sierra Leone instituted a national lockdown, Liberia cordoned off swathes of territory, and in Guinea, panicked residents in one village killed a team that had come to raise awareness about the disease. WHO, with its budget and capacity to respond diminished, has largely been sidelined in the response to Ebola. In a leadership vacuum, high-income countries sent in military assets, the UN Security Council declared Ebola a threat to international peace and security, and UN Secretary-General Ban Ki-moon created a special UN mission. How did this situation arise, and what will it take to bring Ebola under control and prevent future crises? The answers lie in failures of leadership.
WHO should be the global health leader. Under its constitution, WHO was envisaged as “the directing and coordinating authority on international health work”. In describing WHO’s mission recently, however, Director-General Margaret Chan said it is a “technical agency”, with governments having “first priority to take care of their people”. Yet the affected states possess fragile health systems that have proven unable to prevent Ebola’s domestic and transnational spread. WHO itself is constrained. Its budget is incommensurate with its responsibilities, with an operating budget a third of the US Centers for Disease Control and Prevention’s budget. After a 2011 funding shortfall, WHO cut its already insufficient budget by nearly US$600 million. The organisation’s emergency response units were reduced, with some epidemic control experts leaving the agency.Furthermore, WHO controls only 30% of its budget, and member states have co-opted WHO’s agenda through earmarked funds.
In preparing its budget, WHO relied on misplaced confidence that it could mobilise funds rapidly in the face of a crisis, but waiting for donations has led to costly delays. WHO has been constantly catching up in mobilising resources for Ebola: in April, 2014, it sought $4·8 million, by July 31 it set a $71 million goal; and in August made a $490 million appeal, with the UN launching a $988 million appeal weeks later.
WHO oversees the International Health Regulations (IHR), which require 196 states parties to develop public health capacities to detect and respond to public health emergencies of international concern (PHEIC), with states required to cooperate in building these capacities. However, the regulations do not provide incentives, sanction states for failing to cooperate, or allocate responsibility. In 2011, after the 2009 H1N1 influenza PHEIC, an independent Review Committee warned that “The world is ill-prepared to respond…to a global, sustained and threatening public-health emergency”, with health capacities “not now on a path to timely implementation worldwide”. Huge capacity deficits remain and, for some low-income countries, no data are even reported in WHO’s global database. WHO itself did not implement the Review Committee’s proposal for a rapid-response emergency fund.
WHO declared Ebola a PHEIC on Aug 8, triggering temporary non-binding recommendations. Some countries imposed travel bans, contrary to WHO’s recommendations. Affected states, moreover, could not realistically implement WHO recommendations for treatment centres, health worker compensation, and personal protective equipment.
The delayed and fragmented response to Ebola left a vacuum, which led to an unlikely plea from Médecins Sans Frontières for military deployment—logistics, engineering, and supply-chain management. On Sept 16, US President Barack Obama announced a military-led response in Liberia, which could shore-up capacity but will not fill major governance deficits, which require UN action.
Source: The Lancet – Read full article here.