Charles Clift
Senior Consulting Fellow, Centre on Global Health Security
Last week’s report of the independent panel the World Health Organization created to examine its response to the Ebola outbreak fails to establish exactly what went wrong and why.
A pile of used protective clothing on the floor at a World Health Organization health training centre to deal with Ebola victims in the Liberian capital Monrovia. Photo by Getty Images.A pile of used protective clothing on the floor at a World Health Organization health training centre to deal with Ebola victims in the Liberian capital Monrovia. Photo by Getty Images.

The report of the assessment panel which the World Health Organization (WHO) commissioned on its response to the Ebola outbreak was meant to review the roles and responsibilities at the three levels of the organization (headquarters, regions, countries) and the WHO’s actions in the course of the outbreak. But it is weak on analysis and flawed in its central recommendation.

Contradictions

The report recommends the establishment of a WHO Centre for Emergency Preparedness and Response, uniting the currently separate areas of outbreak and humanitarian work – not by simple merger but by establishing new organizational structures and procedures.

This is an attempt, in line with what the WHO has already proposed, to provide a centralized system for emergencies based on ‘command and control’ alongside WHO’s decentralized and bureaucratic structure, with its six self-governing regional offices − which many believe was the root cause of its problems with Ebola. But, as noted in a previous comment, 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.

And the report outlines a structure for the centre which embodies the contradictions inherent in this approach. In ‘normal’ times emergency teams in regional offices would report to the regional director in line with normal WHO practice. However, when an emergency is declared, regional and country emergency staff would report directly to the head of the centre. In an emergency the WHO country representative might be asked to ‘step aside’ in favour of an emergency expert from the centre. This is unlikely to be workable in practice given the WHO’s political and bureaucratic dynamics.

Unanswered questions

There are 21 recommendations in total but many of these are exhortatory rather than concrete and practical, such as ‘WHO must develop an organizational culture that accepts its role in emergency preparedness and response’. The report provides no clear idea of what exactly should be the WHO’s role in an emergency as compared to the multiple other actors in the UN, NGOs and the private sector. The WHO’s view of the report is perhaps implicit in its very perfunctory response to it, which neither comments on the report’s recommendations nor reveals anything new about the WHO’s response.

The WHO received a lot of criticism in the press over its handling of the crisis, including, for example, the alleged transfer of the three affected country office heads, the dysfunctionality of the Africa regional office and the failure of communications between the three levels of the organization. Since the Panel had ‘unfettered access’ to WHO internal documents, a forensic examination and dispassionate analysis of what actually happened and why might have been expected. Yet the report leaves many of the questions about the WHO’s role, responsibilities and actions, including those raised by the press coverage, unanswered.

For example, what were the respective roles of the various parts of the organization at its three levels that usually provide country support for infectious disease outbreaks and humanitarian response and coordination? In particular, why did the WHO’s already established Global Outbreak Alert and Response Network (GOARN), which extraordinarily gets only one passing mention in the report, not have the desired impact when it had successfully responded to Ebola outbreaks since 1996? How did the director-general seek to coordinate the teams at headquarters, the regions and country level? In what ways exactly did the African regional office fail, or has it perhaps been unfairly criticized when the blame lies elsewhere? In what ways did country offices fail and why? The communications team is briefly but heavily criticized in the report but why is there no analysis of the reasons things went so wrong? These are the kind of questions that demanded answers, but the report does not provide them. 

Instead there are generalized statements such as ‘WHO has a technical, normative culture, not one that is accustomed to dealing with such large-scale, long-term and multi-country emergency responses’ and ‘WHO does not have an organizational structure that supports open and critical dialogue between senior leaders and staff’. However true these may be, they are assertions, mainly not supported by any evidence in the report. 

While a report like this is not expected to name and shame people, it is notable that it does not contain the name of anyone at all, or indeed of any WHO department, as if a deliberate decision had been taken to establish a distance between what happened and the individuals and departments who were responsible. People unfamiliar with UN agencies might ask how it is that, if the WHO failed so badly in several areas, no one appears to have been held accountable.

Perhaps the panel should have been given more time to undertake a more detailed analysis of what went wrong but, even so, it delivered the report more than three weeks before the end-July deadline. There is therefore plenty of work in front of the three other panels established to examine the lessons to be learnt from the global Ebola response in a longer time frame, but these will not have the same access to WHO documents. In that sense, an opportunity to establish exactly what went wrong has been missed.

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