The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the
national and international institutions responsible for protecting the public from
the far-reaching human, social, economic, and political consequences of infectious
disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are
needed to mend the fragile global system for outbreak prevention and response, rebuild
confidence, and prevent future disasters? To address this question, the Harvard Global
Health Institute and the London School of Hygiene & Tropical Medicine jointly launched
the Independent Panel on the Global Response to Ebola. Panel members from academia,
think tanks, and civil society have collectively reviewed the worldwide response to
the Ebola outbreak. After difficult and lengthy deliberation, we concluded that major
reforms are both warranted and feasible. The Panel's conclusions offer a roadmap of
ten interrelated recommendations across four thematic areas:
Preventing major disease outbreaks
All countries need a minimum level of core capacity to detect, report, and respond
rapidly to outbreaks. The shortage of such capacities in Guinea, Liberia, and Sierra
Leone enabled Ebola to develop into a national, and worldwide, crisis.
Recommendation 1: The global community must agree on a clear strategy to ensure that
governments invest domestically in building such capacities and mobilise adequate
external support to supplement efforts in poorer countries. This plan must be supported
by a transparent central system for tracking and monitoring the results of these resource
flows. Additionally, all governments must agree to regular, independent, external
assessment of their core capacities.
Recommendation 2: WHO should promote early reporting of outbreaks by commending countries
that rapidly and publicly share information, while publishing lists of countries that
delay reporting. Funders should create economic incentives for early reporting by
committing to disburse emergency funds rapidly to assist countries when outbreaks
strike and compensating for economic losses that might result. Additionally, WHO must
confront governments that implement trade and travel restrictions without scientific
justification, while developing industry-wide cooperation frameworks to ensure private
firms such as airlines and shipping companies continue to provide crucial services
Responding to major disease outbreaks
When preventive measures do not succeed, outbreaks can cross borders and surpass national
capacities. Ebola exposed WHO as unable to meet its responsibility for responding
to such situations and alerting the global community.
Recommendation 3: A dedicated centre for outbreak response with strong technical capacity,
a protected budget, and clear lines of accountability should be created at WHO, governed
by a separate Board.
Recommendation 4: A transparent and politically protected WHO Standing Emergency Committee
should be delegated with the responsibility for declaring public health emergencies.
Recommendation 5: An independent UN Accountability Commission should be created to
do system-wide assessments of worldwide responses to major disease outbreaks.
Research: production and sharing of data, knowledge, and technology
Rapid knowledge production and dissemination are essential for outbreak prevention
and response, but reliable systems for sharing epidemiological, genomic, and clinical
data were not established during the Ebola outbreak.
Recommendation 6: Governments, the scientific research community, industry, and non-governmental
organisations must begin to develop a framework of norms and rules operating both
during and between outbreaks to enable and accelerate research, govern the conduct
of research, and ensure access to the benefits of research.
Recommendation 7: Additionally, research funders should establish a worldwide research
and development financing facility for outbreak-relevant drugs, vaccines, diagnostics,
and non-pharmaceutical supplies (such as personal protective equipment) when commercial
incentives are not appropriate.
Governing the global system for preventing and responding to outbreaks
An effective worldwide response to major outbreaks needs leadership, clarity about
roles and responsibilities, and robust measures for accountability, all of which were
delayed or absent during the Ebola epidemic.
Recommendation 8: For a more timely response in the future, we recommend the creation
of a Global Health Committee as part of the UN Security Council to expedite high-level
leadership and systematically elevate political attention to health issues, recognising
health as essential to human security.
Recommendation 9: Additionally, decisive, time-bound governance reforms will be needed
to rebuild trust in WHO in view of its failings during the Ebola epidemic. With respect
to outbreak response, WHO should focus on four core functions: supporting national
capacity building through technical advice; rapid early response and assessment of
outbreaks (including potential emergency declarations); establishing technical norms,
standards, and guidance; and convening the global community to set goals, mobilise
resources, and negotiate rules. Beyond outbreaks, WHO should maintain its broad definition
of health but substantially scale back its expansive range of activities to focus
on core functions (to be defined through a process launched by the WHO Executive Board).
Recommendation 10: The Executive Board should mandate good governance reforms, including
establishing a freedom of information policy, an Inspector General's office, and human
resource management reform, all to be implemented by an Interim Deputy for Managerial
Reform by July 2017. In exchange for successful reforms, governments should finance
most of the budget with untied funds in a new deal for a more focused WHO. Finally,
member states should insist on a Director-General with the character and capacity
to challenge even the most powerful governments when necessary to protect public health.
These ten recommendations are concrete, actionable, and measurable. High-level political
leadership is now needed to translate this roadmap into enduring systemic reform so
that the catastrophe of the Ebola outbreak will never be repeated.
“We do not have the capacity to respond to this crisis on our own. If the international
community does not stand up, we will be wiped out. We need your help. We need it now.”
Naimah Jackson, Team Leader, Médecins Sans Frontières Ebola Treatment Center, Monrovia.
Address to the UN Security Council, Sept 18, 2014
The west African Ebola epidemic that began in 2013 was a human tragedy that exposed
a global community altogether unprepared to help some of the world's poorest countries
control a lethal outbreak of infectious disease. The outbreak engendered acts of outstanding
courage and solidarity, but also immense human suffering, fear, and chaos, largely
unchecked by high-level political leadership or reliable and rapid institutional responses.
The outbreak continues as of November, 2015. It has infected more than 28 000 people
and claimed more than 11 000 lives,
brought national health systems to a halt, rolled back hard-won social and economic
gains in a region recovering from civil wars, sparked worldwide panic, and cost several
billion dollars in short-term control efforts and economic losses.3, 4 Guinea, Liberia,
and Sierra Leone were most badly affected. The Ebola outbreak is a stark reminder
of the fragility of health security in an interdependent world, and of the importance
of building a more robust global system to protect all people from such risks.
A more humane, competent, and timely response to future outbreaks needs greater willingness
to assist affected populations, and systematic investments to enable the global community
to perform four key functions:
Strengthen core capacities within and between countries to prevent, detect, and respond
to outbreaks when and where they occur.
Mobilise faster and more effective external assistance when countries are unable to
prevent an outbreak from turning into a crisis.
Rapidly produce and widely share relevant knowledge, from community mobilisation strategies
to protective measures for health workers, and from epidemiological information to
rapid diagnostic tests.
Provide stewardship over the whole system, entailing strong leadership, coordination,
priority-setting, and robust accountability from all involved.
The Ebola outbreak emphasised failures in performing all four of these functions.
Clarity about roles, responsibilities, and rules—and accountability for adherence
to them—is essential in a complex system that must involve local, national, regional,
and international actors spanning the public, private, and non-profit sectors. Yet,
this clarity and accountability was fundamentally absent. Without addressing these
governance issues, we will remain wholly unprepared for the next epidemic, which might
very well be more devastating, virulent, and transmissible than Ebola or previous
disease outbreaks.7, 8, 9
The Independent Panel on the Global Response to Ebola is a joint initiative of the
Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine
to review the global community's response to the Ebola outbreak. The 19 members come
from academia, think tanks and civil society around the world, with expertise in Ebola,
disease outbreaks, public and global health, international law, development and humanitarian
assistance, and national and global governance. The Panel took a global, system-wide
view with a special focus on rules, roles, and responsibilities to identify changes
necessary to prevent and prepare for future outbreaks.
This Panel report outlines the main weaknesses exposed during different phases of
the Ebola outbreak, followed by ten concrete, interrelated recommendations across
four thematic areas: preventing major disease outbreaks, responding to major disease
outbreaks, research—production and sharing of data, knowledge, and technology, and
governing the global system, with a focus on WHO.
Our primary goal is to convince high-level political leaders worldwide to make necessary
and enduring changes to better prepare for future outbreaks while memories of the
human costs of inaction remain vivid and fresh.
Systemic weaknesses exposed by the Ebola outbreak
The Ebola outbreak witnessed many types of failures. For analytical purposes, we divide
the epidemic roughly into four phases, underlining the most salient issues that arose.
During the initial phase from December, 2013, to March, 2014, the first infections
occurred in a remote rural area of Guinea where no outbreaks of Ebola had previously
The lack of capacity in Guinea to detect the virus for several months was a key failure,
allowing Ebola eventually to spread to bordering Liberia and Sierra Leone. This phase
underscored the problem of inadequate investments in health infrastructure, despite
national governments' formal commitments to do so under the International Health Regulations
and awareness among donors that many lower income countries would need substantial
external support. It also underscored inadequate arrangements between governments
and WHO to share, validate, and respond robustly to information on outbreaks.
In March, 2014, a second phase began in which intergovernmental and non-governmental
organisations began to respond, starting with Médecins Sans Frontières, which already
had teams on the ground. That month, both Guinea and Liberia confirmed Ebola outbreaks
to WHO. By March 24, Ebola was confirmed in Conakry, home to more than one in seven
Guineans. Two months later Ebola had spread to three capital cities with international
airports. Without any approved drugs, vaccines or rapid diagnostic tests, health workers
struggled to diagnose patients and provide effective care. Without sufficient protective
gear, and initially without widespread understanding of the virus, hundreds of health
workers themselves became ill and died. Despite Médecins Sans Frontières' warnings
about the unprecedented scope of the outbreak,
national authorities in Guinea downplayed it for fear of creating panic and disrupting
economic activity.12, 13 Internal documents
suggest similar concerns might have influenced WHO, which publicly characterised the
outbreak in March as “relatively small still”.
WHO's Global Alert and Response Network sent an expert team to support national efforts,
as did others such as the US Centers for Disease Control and Prevention. However,
those teams withdrew from Guinea and Liberia in May when reported cases decreased,
even as viral transmission continued.
In late May, Sierra Leone became the third country to declare an Ebola outbreak to
WHO. For the first time in the known history of Ebola, the virus had spawned sustained
outbreaks in three countries. This should have raised substantial alarm, as coordination
was weak between the national governments of Liberia, Guinea, and Sierra Leone, the
borders extremely porous, and human movement and trade highly fluid. In late June,
Médecins Sans Frontières labelled the situation as “out of control” and publicly called
for more international attention and resources.
This second phase witnessed three interrelated failures. First, in a failure of political
leadership, some national authorities did not call for greater international assistance
despite the humanitarian crisis, and in some cases downplayed the outbreak. Second,
WHO's in-country technical capacity was weak, shown by its decision to withdraw its
international team too soon and its poor responses in Guinea and Sierra Leone to requests
for technical guidance from ministries of health and health-care providers.18, 19
Third, WHO did not mobilise global assistance in countering the epidemic despite ample
evidence the outbreak had overwhelmed national and non-governmental capacities—failures
in both technical judgment and political leadership.
The third phase began in July as cases, global attention, panic, and responses all
grew. Funding increased, with the World Bank committing US$200 million in the first
major external financing response.
Media attention and public interest substantially increased after the evacuation of
two infected US aid workers from Liberia.
Fear and hysteria in response to Ebola infections in the USA later led to quarantines
of returning aid workers and other measures counterproductive for controlling the
Dozens of countries, private companies, and universities began implementing travel
restrictions, and many airlines ceased flying into the region.
On Aug 7, WHO convened the International Health Regulations Emergency Committee, and
the next day the Director-General officially designated the Ebola outbreak a public
health emergency of international concern (“an extraordinary event which is determined...to
constitute a public health risk to other States through the international spread of
disease and to potentially require a coordinated international response.”
) Detected cases grew exponentially. Ebola treatment centres in all three countries
were stretched beyond capacity and forced to turn away patients at their gates.
A growing lack of trust between population groups and government authorities hindered
community mobilisation and public education.
In the ensuing weeks, the global community mobilised, with new commitments of financing,
health personnel, and logistical support from the African Union, China, Cuba, the
European Union, the UK, the USA, the World Bank, the International Monetary Fund,
and the UN agencies. The UN Security Council passed Resolution 2177 declaring the
outbreak a threat to international peace and security, the only time it has done so
regarding an outbreak and only the second resolution ever (after HIV/AIDS in 2000)
to focus on a disease.
The UN Secretary General created a new entity to coordinate the international response,
the UN Mission for Emergency Ebola Response.
Additionally, trials for two candidate vaccines were launched in Europe and the USA,
and WHO convened an expert group to develop guidance for the ethics of using experimental
Despite increased mobilisation of political attention and resources, this third phase
witnessed several failures. First, public and private restrictions on trade and travel
further harmed an already suffering region and hindered control efforts.16, 28 Second,
the operational response commenced slowly, taking months for funding, personnel, and
other resources to reach the region.28, 29, 30 Third, the creation of the UN Mission
for Emergency Ebola Response bypassed the pre-existing UN body for emergency coordination,
the Office for the Coordination of Humanitarian Affairs, further blurring the lines
of responsibility for international coordination. Fourth, field staff often reinvented
strategies for community mobilisation and contact tracing because relevant lessons
from previous Ebola outbreaks in Uganda and the Democratic Republic of Congo were
not effectively transferred.
Fifth, international staff with Ebola sometimes received experimental therapies (albeit,
the efficacy and risks of which were unknown) and were evacuated while national staff
largely were not, a demoralising and often deadly distinction for many health workers.32,
33 Sixth, there was poor understanding of how to take into account community beliefs,
practices, and solutions, properly address rumours, and involve local leaders—with
sometimes fatal consequences for health workers and communities.
A fourth phase began towards the end of 2014 as the epidemic turned a corner. The
total number of cases began to decline in the hardest hit countries as community leaders
and organisations joined control efforts, even before large-scale global assistance
arrived. Ebola had been imported into Nigeria, Mali, and Senegal in the second half
of 2014. Nevertheless, rapid information sharing, and mobilisation of health workers
for contact tracing and patient care had limited the outbreak in Senegal to one confirmed
In Nigeria, the Nigerian Center for Disease Control, previous experience with polio
eradication efforts and a lead poisoning emergency were all cited as important factors
in successful control of the outbreak in Africa's most populous country.
By the end of January, 2015, more than $5 billion had been committed for the Ebola
response (although the proportion of these funds actually spent on Ebola and in the
affected countries remains unclear).
Research and development efforts were quickly operationalised despite uncertainty
on processes for regulatory approval, with at least three vaccine candidates, three
blood products, and five drug candidates in clinical trials, with WHO playing a coordinating
During this phase, the binding constraints were no longer political attention, funding,
or human resources, but operational coordination, accountability for effective use
of funds, and maintaining momentum to prevent new infections.
Amidst the crisis, many acts of courage, solidarity, innovation, and leadership prevailed,
often at a substantial personal cost. In west Africa more than 800 local health workers
contracted Ebola caring for the sick; more than 500 of those caregivers died.
Community members volunteered to trace contacts, local leaders educated communities,
and religious authorities promoted new burial practices to prevent transmission. Several
non-governmental organisations vocally advocated for a stronger global response, treated
patients, trained health workers, supported community mobilisation and longer-term
recovery efforts. Additionally to massive funding from traditional donors, the African
Union, the Economic Community of West African States, Cuba, and China made substantial
contributions of personnel, funding, logistics, and technology (Huang Y, Council on
Foreign Relations, personal communication).
Private foundations and companies contributed funds, with $245 million from the top
five contributors, along with meaningful in-kind assistance, such as air lifts.
The initiation and conduct of clinical trials were accelerated amidst the challenging
conditions of an outbreak, enabled by the cooperative efforts of industry, research
funders, regulatory authorities in the USA, Europe, and west Africa, scientists, and
directly affected communities.
These positive steps notwithstanding, this Panel's overarching conclusion is that
the long-delayed and problematic international response to the outbreak resulted in
needless suffering and death, social and economic havoc, and a loss of confidence
in national and global institutions. Failures of leadership, solidarity, and systems
came to light in each of the four phases (panel 1
). Recognition of many of these has since spurred proposals for change. We focus on
the areas that the Panel identified as needing priority attention and action.
Summary of system weaknesses exposed across four phases of the Ebola outbreak
Pre-outbreak and Phase 1: December, 2013–March, 2014
Inadequate national investment and donor support for building national health systems
capable of detecting and responding to disease outbreaks
Inadequate arrangements to monitor country commitments to do so
Phase 2: April, 2014–July, 2014
Little incentive for countries to report outbreaks early
Insufficient overall technical capacity among national and international teams
WHO slow to mobilise global attention or assistance
Phase 3: August, 2014–October, 2014
Government and private sector disregard for WHO recommendations regarding travel and
Slow global operational response
Unclear responsibility for international coordination
Weak channels for lessons from previous Ebola outbreaks
Little access to therapies in limited supply, or medical evacuation for national as
opposed to international health workers
Poor understanding of the importance of community engagement
Phase 4: October, 2014–September, 2015
Weak coordination of global operational response
Inadequate transparency on resource flows
Weak accountability for use of funds at all levels
Preventing major disease outbreaks
Preventing small-scale outbreaks from becoming large-scale emergencies needs a minimum
level of core capacities in all countries to detect, report, and respond rapidly (panel
). In the wake of the severe acute respiratory syndrome (SARS) outbreak, governments
committed to developing such core capacities by 2012 under the revised International
Health Regulations (2005), with the 2012 deadline extended for some countries to 2014,
then 2019 after Ebola struck. According to self-assessments, as of 2014, two-thirds
of countries had not met their core capacity requirements and 48 countries had not
responded to WHO queries regarding their readiness.
The International Health Regulations did not include binding obligations for donors
to provide support to poorer countries to meet these obligations, nor to fund WHO
to fulfil its mandate to provide technical assistance.
These shortcomings did not attract serious action or funding until the Ebola outbreak.
Despite unprecedented international financing during the past decade to combat particular
diseases in developing countries, health systems in many resource-poor settings remain
ill-prepared for outbreak response.
No alternate strategy has been developed to supplement these national-level weaknesses.
If countries remain unable to detect outbreaks in a timely way, the rest of the chain
of International Health Regulation-stipulated notifications and responses will fail
Summary of International Health Regulations core capacity requirements for surveillance
Local community level or primary public health response level
Detect cases, report cases, and implement immediate control measures
Intermediate public health response levels
Confirm reported events and support or implement control measures
Assess reported events and report if appropriate
Assess all reports of urgent events within 48 h
Notify WHO immediately
Determine rapidly the control measures needed to prevent domestic and international
Provide support through specialised staff, laboratory analysis of samples, and logistical
Provide on-site assistance as needed to supplement local investigations
Provide a direct operational link with senior health and other officials
Provide direct liaison with other relevant government ministries
Provide, by the most efficient means of communication available, information and recommendations
received from WHO
Establish, operate, and maintain a national public health emergency response plan
Additionally, according to the International Health Regulations, countries agreed
to report potential health emergencies within 24 h to WHO for joint risk assessment,
with the option of doing so confidentially. WHO was also permitted to receive, analyse,
and ask for verification of outbreak information received from non-governmental sources.
Governments might hesitate to report outbreaks publicly for fear of political and
economic repercussions, as occurred in China with SARS in 2003. Yet, history has shown
that early reporting is essential to reduce both the health toll of an outbreak and
its political and economic consequences. Governments agreed in the International Health
Regulations to prompt notification, and in return, were reassured of the curtailment
of unwarranted trade or travel restrictions and support from WHO technical assistance.
During the Ebola outbreak, however, 40 countries and many private firms implemented
restrictions on travel or trade, despite WHO's recommendations against such measures
and the Security Council's warnings about the resulting isolation of affected countries.23,
25, 45, 46, 47, 48
We conclude that several concrete steps must be taken to prevent future outbreaks
from becoming large-scale catastrophes.
Recommendation 1: Develop a global strategy to invest in, monitor, and sustain national
WHO should convene governments and other major stakeholders within 6 months to begin
developing a clear global strategy to ensure that governments invest domestically
in building core capacities and to mobilise adequate external support to supplement
efforts in poorer countries.
There is growing momentum in the wake of Ebola for such investments: the US Government
has committed $1 billion to build core capacities in at least 30 developing countries,
including Guinea, Liberia, and Sierra Leone.
This work is being coordinated under the Global Health Security Agenda, a US-launched
initiative that now consists of nearly 50 countries.
At its June, 2015, summit, the Group of 7 (G7) announced support for 60 countries,
although the G7 did not explicitly commit funds nor agree to a concrete plan.
Financial commitments for recovery have also been made at various Ebola conferences
and summits.52, 53, 54 Other initiatives might also contribute to core capacity building.
These include the Gates Foundation's Child Health and Mortality Prevention Surveillance
the joint Institut Pasteur-China Centers for Disease Control initiative to train west
African scientists in outbreak response,
the Merieux Foundation's laboratory strengthening activities in west Africa,
and the UK's £195 million Fleming Fund for antimicrobial resistance.
These welcome signals need to become sustained budget commitments to support national
or regional plans, such as the Mano River Union Post-Ebola Socioeconomic Recovery
and reviewed systematically beyond this initial phase at forums such as the G7, the
G20, and the World Health Assembly. Furthermore, dialogues about health security should
not be isolated from broader discussions about development financing, including of
the Sustainable Development Goals, as Ebola exposed how substantially an epidemic
could roll back hard-won development gains.
A clear, coordinated plan, supported by a transparent central system for tracking
and monitoring these resource flows, will be needed to minimise fragmentation and
ensure that core capacities are systematically built and sustained. The proposed Accountability
Commission for Disease Outbreak Prevention and Response (recommendation 5) should
monitor investments and results for core capacity building. Further analysis is needed
to estimate the required level of additional funding. Strategic investments for International
Health Regulation core capacities can and should also strengthen broader health systems.7,
60 For example, health information systems can support surveillance and monitoring
of outbreaks and routine health services; training and payment of community health
workers and civil society service providers can help achieve universal health coverage,
while providing an essential trained workforce during emergencies.
Additionally, regional and subregional actors should develop capacities to supplement
gaps at the national level. For example, in Africa, national governments, the African
Development Bank, and other donors should invest in the infrastructural backbone for
a network of laboratories, information systems, and training of African national emergency
responders based in centres of excellence. The Pan American Health Organization has
shown the feasibility of a regional network of centres for disease control, and building
such a network could be a central task of the proposed African Centres for Disease
Control and Prevention. Although the African Centres for Disease Control and Prevention
might be perceived as a competitor to the WHO Regional Office for Africa, a clear
delineation of responsibilities for outbreak response versus other health issues should
enable close collaboration between the two.
Finally, governments must agree to regular, independent, external assessment of their
core capacities. Monitoring requirements should accompany external financing. Assessments
will also be needed in self-financing countries. Some governments objected at the
2015 World Health Assembly to independent assessment.
Nevertheless, a method for peer assessment piloted by five countries through the Global
Health Security Agenda could provide a basis for a monitoring process acceptable for
Recommendation 2: Strengthen incentives for early reporting of outbreaks and science-based
justifications for trade and travel restrictions
Political leaders, governments, and international organisations must strengthen the
set of incentives and disincentives so that governments report disease outbreaks early.
Among these should be stronger disincentives for implementing trade and travel restrictions
without a scientific or public health basis.
WHO should promote transparency by publishing lists of countries that delay reporting
disease outbreaks, while commending countries that rapidly share public information
as Mexico did in 2009 with H1N1. WHO publicly challenged China's Government to be
more transparent about SARS, showing the organisation's potential political power.
WHO should also publicly disclose lists of countries that implement trade and travel
restrictions when WHO Temporary Recommendations advise against them and countries
that do not provide a science or public health rationale for such measures (as required
by the International Health Regulations). Doing so will require a delicate balancing
act between WHO's role as trusted interlocutor with governments on sensitive outbreak-related
information, and its role as guardian of the International Health Regulations. Although
an individual government might object to such scrutiny in the short term, politically
supporting WHO's prerogative to do so serves the long-term interests of global public
Funding bodies such as the World Bank, the Asian Infrastructure Investment Bank, the
African Development Bank, and the New Development Bank (previously known as the BRICs
Development Bank) should create economic incentives for early reporting by committing
to disburse emergency funds rapidly to assist countries when outbreaks strike and
compensating for economic losses that might result. The World Bank's proposed Pandemic
Emergency Financing Facility or the African Union's African Risk Capacity agency
offer the possibility of insurance to mitigate the economic costs linked to outbreak
reporting. The trigger for disbursement should be a risk assessment done under the
aegis of WHO.
Because private firms such as airlines and shipping companies are not directly bound
by public international law, alternate governance mechanisms are needed to prevent
isolating countries when outbreaks strike. The UN Secretary General should convene
relevant industry associations and UN bodies such as the Office for the Coordination
of Humanitarian Affairs, WHO, the International Civil Aviation Organization, and the
International Maritime Organization to identify crucial services provided by private
firms and develop plans to continue such services during emergencies.
These could include designating a UN focal point for the private sector during outbreaks,
designing industry-wide cooperation frameworks, and developing codes of conduct.
Responding to major disease outbreaks
If preventive measures fail and an outbreak escalates into a major crisis, responsibility
for taking action and alerting the broader global community must be clearly designated
Current global response system for responding to public health emergencies of international
As noted, countries agreed as part of the International Health Regulations to notify
WHO of any potential public health emergency of international concern within 24 h
of assessment. WHO rapidly shares information with the Global Alert and Response Network,
a loose network coordinated by WHO of academics, government scientists, non-governmental
organisations, and health volunteers. The Global Alert and Response Network analyses
and assesses reports, deploys investigators, conducts laboratory examination and identification
of the outbreak cause, and advises on further measures, including, as a final resort,
a potential public health emergency of international concern declaration. However,
the Global Alert and Response Network's skeleton staff is too small to deploy in multiple
suspected outbreaks, its budget has been severely cut, and it is not authorised by
WHO to draw public attention to a crisis.
Responsibility for declaring a public health emergency of international concern belongs
to the WHO Director-General, who convenes an Emergency Committee of independent experts
for a recommendation. However, the Director-General did not use her International
Health Regulation-granted authority to convene the Emergency Committee nor declare
a public health emergency of international concern until 5 months after Guinea and
Liberia had notified WHO.
In view of the severity of Ebola virus disease, rapid cross-border spread, weaknesses
of the affected national health systems, the post-conflict setting,
and repeated warnings from non-governmental organisations in the region,
the Director-General had ample reason to raise international attention by convening
the Emergency Committee or declaring a public health emergency of international concern
earlier. The committee responsible for reviewing WHO's performance during the Ebola
outbreak (the WHO Ebola Interim Assessment Panel) and leaked internal emails suggest
several reasons for the delay including concerns about political opposition from west
African leaders, economic ramifications, and a culture within WHO discouraging open
debate about sensitive issues, such as emergency declarations.14, 64 WHO might also
have hesitated because it was sharply criticised for creating panic by declaring a
public health emergency of international concern during the relatively mild 2009 H1N1
Whatever the root causes, the delay emphasised the risks inherent in vesting such
consequential decision making power in a single individual. This risk is heightened
when there is no institutional mechanism of accountability for leadership failures.
After the public health emergency of international concern declaration, a substantial
global response was mobilised. However, this response arrived late, was slow to deliver
funds and health workers, was inflexible in adapting to rapidly changing conditions
on the ground, was inadequately informed about cultural factors relevant to outbreak
control, and was poorly coordinated. The result was, in essence, a $5 billion scramble.
An excessive burden fell on national and international non-governmental organisations
and local communities to do the highest-risk work such as patient care and burials.
The creation of the UN Mission for Emergency Ebola Response as an ad hoc body operating
outside established humanitarian response structures reportedly made coordination
of the crisis response even more difficult.64, 66 Funding was low until the upsurge
of commitments in September, 2014, and, even then, there were long lags between pledges
and disbursement. By one account, nearly $3 billion had been pledged by the end of
2014 but only a third of this money was disbursed.
Furthermore, transparency of financial flows is crucial to minimise duplication, to
ensure aid goes to areas of most need rather than those easiest to assist, and to
ward against mismanagement. However, transparency was, and remains, wholly inadequate:
on the donor side, multiple tracking systems exist but it remains impossible to construct
a clear, comprehensive picture of monetary and in-kind pledges and disbursements across
the many public and private donors.
On the recipient side, who received what funds to do which tasks also remains an opaque
puzzle—and assessing the effect or efficient use of those funds is more difficult
We offer three further recommendations to tackle these issues.
Recommendation 3: Create a unified WHO Centre for Emergency Preparedness and Response
with clear responsibility, adequate capacity, and strong lines of accountability
High-level political leaders must clearly designate who is responsible for responding
when disease outbreaks outstrip national capacities, invest in the capacity to respond,
and ensure accountability for fulfilment of these responsibilities.
Although national governments and non-governmental organisations working on the ground
are the first line of defence when outbreaks arise, WHO is crucial for the second
line of defence when governments need international support or when an outbreak strikes
more than one country. To strengthen WHO's capacity during outbreaks, we welcome the
Stocking Panel's recommendation to create a WHO Centre for Emergency Preparedness
and Response, and offer several additional recommendations regarding its key functions
The centre should merge the outbreak risk assessment and response capacities that
reside in the Global Alert and Response Network with WHO's humanitarian teams, which
presently respond to natural disasters, refugee crises, and other large catastrophes.
Its operational lines of authority from headquarters to regions and countries should
be clearly designated. The centre should assess risks on the basis of the information
that countries and others provide to WHO, and mobilise necessary laboratory, epidemiological,
clinical, communications, and logistical responses. It should have powerful analytical,
data processing, and advisory capacity to command respect in both policy and scientific
communities. The centre should develop rapid response and strong coordinating capacity,
and be able to assemble the world's best expertise to tackle disease threats. Between
crises, the centre should develop protocols, build relationships, and negotiate agreements
with governments, multilateral organisations, non-governmental organisations, private
firms, and other actors to mobilise rapidly during emergencies, including strengthening
capacities in developing countries so that they might better respond nationally and
participate internationally. In a multicountry outbreak, the centre should ensure
government-to-government coordination by establishing channels of direct communication
for rapid information sharing. It should be responsible for building a virtual global
health workforce from both industrialised and developing countries by setting standards
for certifying crisis responders, ranging from communications experts and logisticians
to surgeons and managers. These responders would continue working for their home organisations,
but provide surge capacity in a crisis. Finally, the centre should provide technical
assistance to countries to build and maintain International Health Regulation-mandated
The centre should have its own Executive Director who is accountable for performance
jointly to a separate Board of Directors and to the Director-General. The multistakeholder
Board should include broad representation of governments from each WHO region, scientific
expertise including about animal health, operational responders from all sectors,
and funders. The Executive Director should inform the Board immediately when the Centre's
risk analysis suggests that coordinated international action is needed and mobilise
an appropriate response. Similar governing structures have worked effectively for
WHO-affiliated entities including the Global Polio Eradication Initiative, the International
Agency for Research on Cancer, UNITAID, and the Special Programme for Research and
Training in Tropical Diseases.
The centre's budget should be protected and adequately resourced through a dedicated
revolving fund. The fund should immediately disburse money for rapid scale-up when
a crisis strikes, then be replenished from funds raised for that crisis to be ready
for the next one.
The centre and its Board should work closely and routinely with the Director-General
so that the highest levels of leadership are constantly aware of evolving disease
threats, and can marshal WHO's legal, political, and human resources at regional and
country levels when needed. WHO should use its International Health Regulation-granted
authority to expedite access to affected sites by technical teams and pressure any
state that impedes international responses to, or obscures, disease threats in its
The centre must have access to sensitive outbreak information that countries are required
to share with WHO; further analysis is needed as to whether this would require amendment
to the International Health Regulations.
A third line of defence will be needed if the initial response does not succeed and
an outbreak becomes a humanitarian crisis (eg, a UN level 3 emergency
), threatening not only public health, but also political, economic, and social stability.
International coordination of the large-scale effort needed in this case should be
done by the Office for the Coordination of Humanitarian Affairs. However, because
the Office for the Coordination of Humanitarian Affairs (and most other humanitarian
actors) do not specialise in crises precipitated by disease outbreaks, they should
develop in-house capacity and a broad coordination framework with the health sector
for such emergencies.
Recommendation 4: Broaden responsibility for emergency declarations to a transparent,
politically protected Standing Emergency Committee
Member states should amend the International Health Regulations to broaden responsibility
for declaring a public health emergency of international concern. The Director-General
convenes, and is advised by, an ad hoc Emergency Committee constituted from a list
of independent experts; however, authority and responsibility to declare a public
health emergency of international concern rests exclusively with the Director-General.
We recommend the creation of a Standing Emergency Committee that meets regularly,
with the mandate to declare a public health emergency of international concern by
a majority vote of its members. The emergency declaration should trigger other actions,
such as financial disbursements by development banks, emergency data-sharing and specimen-sharing
rules, and emergency regulatory procedures for new drugs, vaccines, and diagnostics
(recommendations 6 and 7). The Director-General should chair, communicate, and explain
the Standing Emergency Committee's decisions. Following an open call for nominations,
the Director-General would appoint the first members; thereafter, the Standing Emergency
Committee itself would periodically vote in new members to preserve its independent
character. Minutes and votes of Standing Emergency Committee members should be published
immediately following each meeting for the sake of transparency, to build external
confidence, reduce political interference, and strengthen the committee's hand against
resistant states. Similarly to other institutions responsible for technically complex
yet politically consequential decisions, such as central banks or drug regulatory
authorities, the Standing Emergency Committee must be protected from political pressure
that might interfere with its judgment.
The committee should possess high-level public health expertise and base its decisions
on scientific principles and evidence, assessing risks for human health, disease spread,
and international traffic. The Standing Emergency Committee should have adequate economic
expertise to weigh the risks of disrupted trade and travel against those posed by
the outbreak and advise on how to ameliorate economic harm.
The Standing Emergency Committee should also issue early warnings of major potential
risks on the basis of continuing assessments done by the WHO Centre. The committee
should also consider replacing the present binary system, which calls for determining
the presence or absence of a public health emergency of international concern, with
a graded system of warnings.
Finally, the Standing Emergency Committee should publish an annual report detailing
its activities to ensure public accountability and continued political attention to
health threats. The Committee should be financed purely through assessed contributions
to protect against undue donor influence.
A committee does not by definition operate more effectively than an individual, and
might succumb to risk aversion and dysfunction; nevertheless, the combination of measures
described above should provide the Standing Emergency Committee with the autonomy
and capacity for credible, authoritative decision making.
Recommendation 5: Institutionalise accountability by creating an independent Accountability
Commission for Disease Outbreak Prevention and Response (Accountability Commission)
The UN Secretary General should create an Accountability Commission as an independent
body comprised of civil society, academia, and independent experts doing real-time
and retrospective system-wide assessment of global responses to major disease outbreaks.
The Accountability Commission would track and analyse the contributions and results
achieved by national governments, donors, UN agencies, international and national
non-governmental organisations, and the private sector. All major actors would be
expected to share information promptly with the Accountability Commission about financial,
in-kind, or operational contributions; the the Accountability Commission should publish
the names of organisations unwilling to share such information. The Accountability
Commission would assess aid effectiveness, including funds committed, paid, disbursed,
and spent; both short-term and long-term accomplishments achieved with those funds;
and the timeliness, effectiveness, cultural appropriateness, and equity of the response
for intended beneficiaries. The Accountability Commission should liaise directly with
and provide a forum for representatives of communities directly affected by outbreaks.
Finally, it should monitor efforts to build and sustain national core capacities.
The Accountability Commission would report to the World Health Assembly and the Security
Council's Global Health Committee (recommendation 8), and publish its findings regularly
during and after each public health emergency of international concern. After an open
call for nominations, the Secretary General would appoint the first members; thereafter,
the Accountability Commission itself would periodically vote in new members to preserve
its independent character. The Accountability Commission would offer an important
multistakeholder platform for various constituencies involved in and affected by disease
outbreak responses. This proposal builds on analogous efforts to strengthen system-wide
accountability for other global efforts, such as the UN Commission on Information
and Accountability for Women's and Children's Health
and the Independent Monitoring Board of the Global Polio Eradication Initiative, credited
with helping to reinvigorate the performance of this effort.
The Accountability Commission would be a more permanent institution, however, with
a broader mandate than these two previous initiatives.
Research: producing and sharing data, knowledge, and technology
Producing and rapidly sharing knowledge during outbreaks is essential. However, reliable
systems for rapid transmission of epidemiological, genomic, and clinical data were
not established during the Ebola epidemic. Although governments in the three worst
affected countries transmitted epidemiological information to WHO, robust channels
were not established for direct data exchange and coordination between the three capitals.
Although some researchers shared genomic sequencing data early in the outbreak through
an open access database, other researchers later withheld such data from the public
And although care providers and researchers collected thousands of patient samples,
now housed in laboratories in west Africa and worldwide, no clear arrangements exist
for scientists to access those samples,
for their safe handling, or to ensure that west African patients benefit from the
findings or technology that might result.
Previous epidemics show that better arrangements are feasible. During the 2003 SARS
outbreak, WHO established online systems for data sharing among a worldwide network
of scientists, enabling researchers to identify the virus, sequence its genome, and
understand its characteristics.
In 2006, an international consortium of researchers agreed to data sharing norms for
influenza, which enabled real-time dissemination and publication of epidemiological
and clinical data during H1N1 in 2009.
The Consortium for the Standardization of Influenza Seroepidemiology helps to coordinate
a global community of researchers working on influenza serology. Furthermore, after
4 years of intergovernmental negotiations, the 2011 WHO Pandemic Influenza Preparedness
Framework achieved a delicate balance between sharing samples and access to the resulting
technology.76, 77 However, no analogous framework exists for other pathogens.
Access to knowledge embodied in the form of technologies has been a particularly difficult
issue. As noted, no drugs, vaccines, or rapid diagnostic tests had been approved for
Ebola when the outbreak began. Although scientists had identified the virus nearly
four decades earlier and basic research had advanced understanding of the disease,
Ebola was not an attractive target for industry investment in research and development,
nor was it high on the public health research agenda. Somewhat serendipitously, the
US and Canadian Governments had years earlier made defence-related investments in
Ebola, which meant that university and pharmaceutical industry researchers had developed
several experimental drug and vaccine candidates when the outbreak hit.
As noted, clinical trials for vaccines and drugs were launched in record time (with
encouraging results for one vaccine candidate reported in July, 2015).
Nevertheless, the overall research and development effort could have moved faster
if there had been investments beforehand to advance candidate products through phase
1 or 2 trials and a system to prioritise the most important technologies. For example,
effective rapid point-of-care diagnostics could have enhanced contact tracing, counteracted
community resistance and denial, protected health workers, reduced patient loss to
follow-up, eased overburdened treatment centres, and supported the continued operation
of shipping and airline services. A systematic way of posing and answering operational
research questions, such as the relative merits of using intravenous fluids for patient
care, would also have strengthened the response. Furthermore, WHO provided valuable
technical leadership about the ethics of using unproven therapies, but little guidance
on how strictly limited quantities of drugs should be rationed. West African health
workers and patients were largely denied access to the stocks sometimes available
to international staff.
In several instances, WHO proved its capacity to lead, convene, coordinate, and establish
norms among a broad range of public and private actors on research and development
and data sharing. Additionally to its guidance about experimental therapies, WHO convened
research and development actors in mid-2014 and late-2014, and again at a global Ebola
research and development summit in May, 2015. In July, 2015, WHO also issued guidance
about accelerating regulatory approval of technologies in emergencies. WHO also convened
a meeting in September, 2015, to build norms for open data sharing as part of an effort
to develop a “blueprint” to guide the collective research and development efforts
of industry and governments for emergencies. These successful efforts should be institutionalised
to better govern knowledge production and sharing in future outbreaks.
Recommendation 6: Develop a framework of rules to enable, govern and ensure access
to the benefits of research
Before the 2016 World Health Assembly, WHO should convene governments, the scientific
research community, industry and non-governmental organisations to begin developing
a framework of norms and rules for research relevant to disease outbreaks. The framework's
goal would be to provide guidance on three interrelated issues:
Access to data and samples to enable and accelerate research, which would involve
rapid sharing of epidemiological surveillance and clinical data to inform outbreak
control strategies; incentives and platforms for open sharing and access to genomic
sequencing data; access to specimen samples (with appropriate biosafety measures).
Appropriate conduct of research, including improved ethical standards for research
and development (eg, including involving affected populations in setting research
priorities, patient participation and consent); previous agreement about experimental
protocols, such as trial design, to speed clinical trials when outbreaks strike;
access to clinical trial data, such as publication of negative and positive results;
clear pathways for approval by stringent regulatory authorities and in countries of
use; and building on and investing in research capacities in epidemic-affected countries.
Equitable access to the benefits of research, including priority, affordable access
to newly developed health technologies for affected populations, including health
workers; and ethical guidelines for rationing products with limited availability.
An overarching framework is needed to bring coherence and fill gaps in the fragmented
system of international rules shaping outbreak-related research (including the International
Health Regulations, Pandemic Influenza Preparedness Framework, Convention on Biological
Diversity and its Nagoya Protocol, Agreement on Trade Related Aspects of Intellectual
Property Rights, and numerous guidelines and agreements for data ownership and sharing
among scientists). The framework would include both non-binding norms such as guidelines
or codes of conduct, and binding rules such as contractual obligations or international
law. Further analysis is needed to specify the most appropriate instruments for each
Some norms would apply at all times to prepare for potential outbreaks; others could
be limited to and triggered by a public health emergency of international concern
declaration. Establishment of such norms in advance would strengthen preparedness
and reduce counter-productive competition between researchers or institutions during
Ideally, such a normative framework would cover all pathogens with the potential to
cause major outbreaks. However, in view of the complexity and political difficulties
reaching agreement on these issues, a feasible starting point might be to develop
a pilot framework for one or several diseases such as viral haemorrhagic fevers. Lessons
from this pilot could subsequently be applied to expanding the framework to other
pathogens. The Accountability Commission (recommendation 5) should monitor progress
towards developing this framework and subsequently monitor adherence to it.
Recommendation 7: Establish a global facility to finance, accelerate, and prioritise
research and development
The UN Secretary General and the WHO Director-General should convene in 2016 a high-level
summit of public, private, and not-for-profit research funders to establish a global
financing facility for research and development for health technology relevant for
major disease outbreaks. The facility would support manufacturing, research, and development
for drugs, vaccines, diagnostics, and other non-pharmaceutical supplies (such as personal
protective equipment) where the commercial market does not offer appropriate incentives.
For known pathogens, the facility could invest in bringing candidate drugs, vaccines,
technology platforms, and other relevant products through proof of concept, phase
1, and phase 2 testing in humans, so that they are ready for wider testing, manufacturing,
and distribution when an outbreak strikes. During an outbreak the facility would rapidly
mobilise finance for priority research and development projects, such as diagnostics
for novel pathogens.
The establishment of a similar fund for diseases affecting developing countries was
a central recommendation of the 2012 report of the WHO Consultative Expert Working
Group on research and development.
As a result, a pooled international fund was created to support “demonstration projects”
that test new research and development business models, such as open knowledge innovation
and de-linkage of research and development financing from end product prices. With
a management structure already established, the demonstration projects offer an important
option for pursuing research and development for Ebola or other diseases.
The global financing facility should be a lean, efficient entity that mobilises and
strategically deploys resources. It would not be a monolithic entity nor the sole
funder for epidemic-related research and development because some pluralism and competition
among funders is desirable. Nevertheless, a global facility would offer the advantage
of enabling coordination between different research funders through a common framework,
strengthening networks between researchers, establishing processes for priority setting,
and reducing transaction costs for both grantees and smaller donors.82, 83 It could
also require information sharing between researchers as a condition of funding, thereby
giving teeth to the data-sharing framework (recommendation 6). Intellectual property
or any other asset resulting from these investments should be managed as a public
good to enable follow-on innovation, open knowledge sharing, access to technology,
and a fair public return on investment. Support for a global research and development
financing mechanism now seems to be growing, as shown in calls for a $2 billion global
fund for vaccine development for pandemics,
a $2 billion global fund for antimicrobial resistance,
and a $2–3 billion global fund that would cover emerging infectious diseases, neglected
diseases, and antimicrobial resistance.
Governing the global system for preventing and responding to outbreaks
An effective global system for preventing and responding to outbreaks needs well coordinated
and appropriately resourced actors to fulfil clearly defined roles and responsibilities
and to hold each other accountable for doing so (table
). Many actors have crucial roles in this complex system: national governments have
the main responsibility for their populations' health. National governments are also
responsible for immediately sharing information with neighbouring countries and the
international community in the event of a potential public health emergency of international
concern. They also hold responsibility for calling for international assistance if
domestic capabilities prove inadequate.
Roles of WHO and other organisations in disease outbreaks
Role of WHO
Roles of other organisations
Capacity building function
Strengthen core capacities within and between countries to prevent, detect, and respond
Support governments with technical and scientific knowledge and advice
Financing by major public and private donors; technical assistance by specialised
agencies and non-governmental organisations
Mobilise external assistance when countries unable to prevent an outbreak from becoming
Raise awareness of major disease events; declare public health emergencies of international
concern as appropriate; early-stage rapid response to outbreaks; convening for resource
Financing by development banks, Global Fund, and GAVI; financing by other major public
and private donors; operations by UN humanitarian aid agencies, NGOs, and foreign
medical teams; advocacy by civil society
Rapidly produce and widely share relevant knowledge (eg, community mobilisation strategies,
protective measures for health workers, epidemiological data, and rapid diagnostic
Assess disease threats worldwide; establish technical norms, standards, and guidance;
convene to negotiate rules for knowledge sharing
Knowledge production by non-governmental organisations, community leaders, social
scientists, research funders, scientific researchers, pharmaceutical industry, and
Political, scientific, technical leadership
Coordinate early outbreak response; convening stakeholders to resolve conflicts and
UN coordination if outbreak becomes a humanitarian crisis
Convening stakeholders to set priorities
Hold governments accountable for adherence to International Health Regulations
Civil society and media
In turn, international actors are responsible for supporting national governments
individually and collectively. WHO should play a central part in monitoring, assessing,
and responding to disease outbreaks. National and regional agencies for disease control
and academies of science also offer important technical capacities for managing outbreaks.
Development banks are responsible for mobilising and disbursing financing to support
governments and collective action. The international humanitarian system, including
the Office for the Coordination of Humanitarian Affairs, UNICEF, the World Food Programme,
the UN High Commissioner for Refugees, other UN bodies, and non-governmental organisations
are responsible for mounting an effective operational response if an outbreak escalates
into a humanitarian crisis. The research community is responsible for producing relevant
knowledge on the outbreak, and developing and producing technologies to intervene.
Civil society, including academia and the media, play a crucial part in drawing attention
to unmet needs, neglected challenges, and systemic failings, and demanding accountability
from responsible actors. Finally, the UN Security Council is responsible for addressing
threats to international peace and security.
Ebola developed from a relatively small outbreak into a large-scale emergency because
of the failures of multiple actors to fulfil their mandated roles and responsibilities.
Our final three recommendations outline the institutional changes needed to prevent
such failures from recurring.
Recommendation 8: Sustain high-level political attention through a Global Health Committee
of the Security Council
In recognition of health as an essential facet of human and national security, the
UN Security Council should establish a Global Health Committee consisting of government
representatives. The Committee's main goal would be to expedite and elevate political
attention to health issues posing a serious risk to international peace and security
and provide a prominent arena to mobilise political leadership. Specifically, the
Committee would monitor and publish an annual report on progress in building a strong
and effective global health security system, taking into account analyses from the
Accountability Commission and WHO. The Committee would also address alleged non-compliance
with International Health Regulation provisions on trade and travel measures. The
Committee would not declare public health emergencies of international concern. This
decision would remain technically driven and under the authority of WHO. The Committee
would not be able to veto WHO decisions or reports of the Accountability Commission.
Rather, the Committee's main role would be as an arena for high-level attention to
health threats and a forum for problems not adequately resolved by the WHO governing
WHO in the global system
WHO is an essential hub in the global system for health security. However, evidence
of confusion and disagreement about its role is ample.
Since the 19th century, cross-border disease control was the first and most widely
accepted rationale for intergovernmental health cooperation.
Yet, in the wake of the global financial crisis when WHO laid off more than a tenth
of its headquarters staff, outbreak response capacity was deeply and disproportionately
Disease outbreaks are not the only important work for WHO, but they are foundational
to the organisation's mandate.
Within a global system for disease outbreak response, what should be WHO's essential
role? WHO's near-universal state membership, governance structure, and deep relationships
with health ministries situate it uniquely to perform four core functions (table):
support governments in building national core capacities for prevention, surveillance,
and response through technical and scientific knowledge and advice; assess and provide
rapid early response to outbreaks, raise awareness of major disease events, and declare
public health emergencies of international concern when appropriate; establish technical
norms, standards and guidance; and convene actors to set goals, mobilise resources,
resolve conflicts, and negotiate rules. Performance of these functions needs strong
political, scientific, and normative leadership with solid backing from member states.
However, WHO's failings on these core functions during the Ebola outbreak have now
produced an existential crisis of confidence. Ebola exacerbated a trend since the
1990s of many governments and other organisations working around WHO. Decades of reducing
assessed contributions in real terms has starved the organisation of resources. Donors
have earmarked voluntary contributions, effectively controlling nearly 80% of WHO's
budget by 2015.
The result is an organisation that seems to have lost its way. Although the budget
has more than doubled from US$1·6 billion in 1998–99 to US$4 billion in 2012–13, the
organisation itself controlled an ever-shrinking share. One casualty of recent decisions
was WHO's reduced ability to control cross-border disease outbreaks, a core task for
which it was created in 1948.
In the wake of Ebola, the organisation's traditional claims of legitimacy based on
near-universal state membership no longer seem sufficient. A true recovery will need
far greater willingness by member states to entrust resources and delegate authority
to WHO, but it has rarely been in a weaker position to command such trust and authority.
Confidence in the organisation's capacity to lead is at an all-time low. Calling for
additional staff or a larger budget will not address this. WHO must find a way to
prioritise what it does, and regain its credibility, independence, and legitimacy
to perform its core functions (table). Breaking out of this 20-year impasse will demand
clear commitment and a different kind of leadership by WHO to implement fundamental
reforms under a tight timeline, matched by an equally clear commitment by member states
to reward such reform with appropriate authority and resources. WHO performed a key
coordinating function in research and development during the Ebola epidemic. It was
also central to controlling nine previous Ebola outbreaks, SARS, and other epidemics.
These examples are important reminders of what WHO can do under determined leadership.
WHO is in a formal reform process that was spurred by a budget crisis in 2011; in
some ways, it has been in a perennial process of reform since at least the 1990s.
These previous efforts are a reminder that high-level political leadership, such as
the engagement of heads of state, will be needed if the outcome is to be different
this time. At this point, anything less than fundamental reform will mean continued
marginalisation and decline, alongside increasing vulnerability for global public
Recommendation 9: A new deal for a more focused, appropriately financed WHO
To rebuild trust, respect, and confidence within the international community, WHO
should maintain its broad definition of health, but substantially scale back its expansive
range of activities to focus on core functions. The scope of WHO's work would thus
continue to embrace the full range of health issues, but its functions should be far
more circumscribed. We restrict our analysis to core functions in infectious disease
outbreaks. However, there remains the need to define WHO's core functions in other
key areas of work, such as non-communicable diseases, injuries, environmental health,
health systems, and social determinants of health. For this purpose, the January 2016
Executive Board should launch a fundamental review of the organisation's constitution
and mandate to define its core functions. This review should identify and hand over
non-core activities to other actors, thereby streamlining WHO's activities. It should
also examine which core functions are not being fulfilled or adequately funded.
The financing model for WHO is unstable and politically vulnerable. The January 2016
Executive Board should also begin developing a new financing model for assessed contributions
focused on core functions and draft a transparently implemented policy about when
to accept or reject voluntary contributions at headquarters, regional, and country
offices. If WHO strictly defines its core functions and accelerates other good governance
reforms (recommendation 10), member states should shift most of its financing to assessed
and non-earmarked voluntary contributions.
Recommendation 10: Good governance of WHO through decisive, timebound reform, and
Restoring credibility demands that WHO institutionalises accountability mechanisms,
strengthens and clarifies how it works with other actors, and fosters strong leadership.
The January 2016 Executive Board should launch a process to implement four new policies
for WHO to meet basic principles of good governance: establish a freedom of information
policy, with appropriate safeguards; create a permanent Inspector General's office
to monitor overall performance of the organisation and its entities, reporting to
the Executive Board; conclude continuing work on the Framework of Engagement with
Non-State Actors to better govern the way WHO interacts with civil society, academia,
foundations, and the private sector; and revise human resource policies to attract
or retain well qualified staff, including for leadership positions, while letting
go of chronic underperformers.
The Executive Board should seize the short window of opportunity available for such
reforms by giving a strong mandate to an Interim Deputy for Managerial Reform reporting
to the Director-General to implement these policies by July, 2017 (before the next
Director-General takes office). In line with the reformed approach to human resources,
all upcoming leadership selection and election processes at headquarters, regional,
and country offices should be based on personal, technical, and leadership merits.
The Executive Board, with the participation of civil society, should do an annual
appraisal of senior leadership to strengthen accountability.
As the next Director-General election approaches, member states should insist on a
dynamic leader with a strong record of focusing on people, able to manage crises,
implement reforms, and communicate strategically. A key attribute should be proven
high-level political leadership with the character and capacity to challenge even
the most powerful governments when necessary to protect public health. It is in the
collective interest of member states to have a strong, empowered leader heading the
Taken together, the Panel's ten recommendations provide a vision for a more robust,
resilient global system able to manage infectious disease outbreaks (panel 3
, figure 2
). Preventing small outbreaks from becoming large-scale emergencies demands investment
in minimum capacities in all countries and encouragement of early international reporting
of outbreaks by adhering to agreed international rules. Responding effectively to
outbreaks demands much stronger operational capacity within WHO and within the broader
aid system if outbreaks escalate into humanitarian emergencies, a politically protected
process for WHO's emergency declarations, and strong mechanisms for the accountability
of all involved actors, from national governments to non-governmental organisations
and from UN agencies to the private sector. Mobilisation of the knowledge needed to
combat outbreaks will require an international framework of rules to enable, govern,
and ensure access to the benefits of research, and financing to develop technology
when commercial incentives are inappropriate. Finally, effective governance of this
complex global system demands high-level political leadership and a WHO that is more
focused and appropriately financed and whose credibility is restored through the implementation
of good governance reforms and assertive leadership.
Summary of recommendations
Preventing major outbreaks
Develop a global strategy to invest in, monitor, and sustain national core capacities
Strengthen incentives for early reporting of outbreaks and science-based justifications
for trade and travel restrictions
Responding to major outbreaks
Create a unified WHO Centre for Emergency Preparedness and Response with clear responsibility,
adequate capacity, and strong lines of accountability
Broaden responsibility for emergency declarations to a transparent, politically protected
Standing Emergency Committee
Institutionalise accountability by creating an independent Accountability Commission
for Disease Outbreak Prevention and Response
Research: producing and sharing data, knowledge, and technology
Develop a framework of rules to enable, govern, and ensure access to the benefits
Establish a global facility to finance, accelerate, and prioritise research and development
Governing the global system
Sustain high-level political attention through a Global Health Committee of the Security
A new deal for a more focused, appropriately financed WHO
Good governance of WHO through decisive, time bound reform and assertive leadership
Framework of reform proposals
(A) Outbreak response involves several overlapping systems, including the humanitarian
system, the UN System, and the biomedical and research development system. The scope
of the proposed Accountability Commission would include all of these. Examples of
organisations within each system are shown. ILO=International Labour Organisation.
OIE=World Organisation for Animal Health. FAO=Food and Agriculture Organisation. OCHA=Office
for the Coordination of Humanitarian Affairs. WFP=World Food Programme. LNGOs=local
non-governmental organisations. CBO=community-based organisations. INGOs=international
non-governmental organisations. (B) Taking a closer look within the WHO, several changes
are proposed. The proposed Centre for Emergency Preparedness and Response would sit
within WHO, coordinating the many actors involved in global outbreak response and
sharing and receiving information with those actors. The Centre's governing Board
is to be comprised of member states and non-state actors. The creation of a Standing
Emergency Committee would replace the current ad hoc International Health Regulation
Emergency Committee. The Standing Emergency Committee will meet and receive information
from the Emergency Centre regularly, with the mandate to declare a public health emergency
of international concern by a majority vote of its members. The Director-General would
chair this committee. A permanent Inspector General's office is proposed, along with
other good governance reforms (not depicted in the figure) such as a freedom of information
The human catastrophe of the Ebola epidemic that began in 2013 shocked the world's
conscience and created an unprecedented crisis. It exposed deep inadequacies in the
national and international institutions responsible for protecting the public from
the far-reaching human, social, economic and political consequences of disease outbreaks.
The reputation and credibility of WHO has suffered a particularly fierce blow. Ebola
brought to the forefront a central question: is major reform of international institutions
feasible to restore confidence and prevent future catastrophes? Or should leaders
conclude the system is beyond repair and take ad hoc measures when the next major
After difficult and lengthy deliberation, our Panel concluded major reforms are warranted
and feasible. The Panel refined its recommendations into a roadmap of ten interrelated
reforms that in combination can strengthen the global system for outbreak prevention
The roadmap gives greatest weight to clarification of the roles and responsibilities
of the many actors involved in outbreak response, investing in capacities to fulfil
those roles, and demanding accountability for meeting those responsibilities. These
measures are concrete, actionable, and measurable. Success requires one other essential
ingredient: high-level political leadership determined to translate this roadmap into
enduring systemic reform so that the immense human suffering of the Ebola outbreak
will not be repeated.