Charles Clift
Senior Consulting Fellow, Centre on Global Health Security
Policy failure over the Ebola response has prompted the WHO to seek to centralize its emergency operations. But whether this strategy will work in the context of the organization’s devolved governance structure – which in effect means there are seven WHOs, not one – is unclear.
Health care workers go through an emergency simulation Ebola exercise at the Tanjung Emas port on 4 December 2014 in Semarang, Indonesia. Photo by Getty Images.Health care workers go through an emergency simulation Ebola exercise at the Tanjung Emas port on 4 December 2014 in Semarang, Indonesia. Photo by Getty Images.

The executive board of the World Health Organization (WHO) agreed a comprehensive resolution on its response to the Ebola crisis in a special session on 25 January. After the WHO was widely criticized for its perceived inadequacies in dealing with the Ebola outbreak in West Africa, the resolution asks for a transformation in the way the organization works in health emergencies. The WHO admits there is substance in these criticisms – with Margaret Chan, WHO’s director-general (DG), acknowledging shortcomings in WHO’s ‘administrative, managerial and technical infrastructures’. But there are serious questions about the practical and political feasibility of what the WHO and its member states are being asked to do.

The huge human and economic cost of Ebola – nearly 10,000 deaths and $4 billion in emergency support from 70 countries – means that the issue of future preparedness has moved beyond the usual ghetto of health experts and health ministers to engage, at the highest level, government leaders, the UN and the World Bank.

And the WHO’s inadequacies are now being recognized five years after Margaret Chan herself, to her credit, initiated a programme of reform at the WHO. Yet during this time member states acquiesced in the cutting of the WHO’s emergency response budget, and the WHO and its member states failed to respond meaningfully to the recommendations of the 2011 independent review of the last major outbreak – the 2009 H1N1 pandemic. The review recommended, in particular, the establishment of a Global Health Emergency Workforce and a contingency fund for public-health emergencies of at least $100 million to support a surge capacity in the WHO.

Moreover, many have suggested that a principal reason for the WHO’s inadequate response to Ebola is the fact that its six regional offices have an autonomous status. Their heads are elected by regional member states and it is to them that they owe their principal allegiance, not the DG in Geneva. Thus the African regional office, on the frontline for Ebola, has been criticized for not responding appropriately and expeditiously, and the Geneva headquarters for not acting early enough to address the problem. Eventually Geneva appears to have exerted its control, notably by replacing the heads of its country offices in all three affected countries. But the reform programme has not really addressed this central and long-recognized problem in the WHO’s governance structure – that there are in fact not one but seven WHOs. This is a deficiency which is cruelly exposed when circumstances dictate decisive and timely action based on good communication and clear lines of command. 

Therefore it was amidst considerable publicity that the WHO held a special session of its executive board on Sunday to consider what more needed to be done to end the current outbreak and ensure that the WHO would be ready to respond when the next health emergency arises.

A working group of member states, led by South Africa and the US, produced a resolution setting out the WHO’s response, which was approved at the special session amidst much clapping and mutual congratulation. The resolution is over nine pages long, perhaps a record, and contains a multitude of recommendations, including resuscitating the 2011 review recommendations of a Global Health Emergency Workforce (watered down to a ‘more extensive global, public health reserve workforce’) and a contingency fund (the UK offered $10 million in principle to this fund). In addition it requested the DG to commission an interim assessment by a panel of outside independent experts to review all aspects of the WHO response and report by May this year.

A central theme of the resolution is an attempt to reassert the authority of the DG over the whole organization. The executive board said that country and regional offices should ‘cooperate with and support’ the DG; that all ‘relevant authorities… rest with the Director-General for outbreaks and emergencies’ and that it ‘supports the Director-General in exercising her authority to add or change staff… at the country and regional level’. So this is an attempt by member states to reassert the authority of the DG over the whole organization in the context of health emergency preparedness – somehow to bypass the bureaucratic and political dynamics embedded in the structure of the organization that work in precisely the opposite direction. According to the New York Times, ‘some WHO officials hoped the executive board would go further…calling for a command-and-control-type leadership structure… for simplifying emergency management’.  As it is the resolution invites the DG ‘to consider (italics added) assigning… a Special Representative… to be responsible for all aspects of coordination at all three levels of the Organization’. 

The resolution points a direction, but the devil will be in the detail. What would be the size and composition of an ‘emergency workforce’? How would it be financed given the WHO’s straitened budgetary position? How would a contingency fund work and who would contribute how much? Will the DG in practice be able to add or change staff at regional and country level given the WHO’s decentralization?

All these questions and many others raised by the resolution now need to be addressed urgently by the WHO secretariat. But it is very much open to question whether a strategy which seeks to centralize the WHO’s emergency operations, while leaving undisturbed WHO’s ‘normal’ decentralized governance structure, is feasible either bureaucratically or politically. As UK Chief Medical Officer Dame Sally Davies said after the meeting: ‘Now we have to make it real. That’s going to be difficult.’

This article was corrected on 29 January to state that the UK offered $10 million to a proposed contingency fund; the original version of the article incorrectly stated the figure as £10 million.

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