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World’s richest countries failed to deliver an urgent response to the Ebola crisis By Debbie Hiller, Humanitarian Policy Adviser, Oxfam

‘We must do more, and do it faster,’ said Tony Banbury, the UN Secretary General’s Special Representative on Ebola, and Head of the UN Mission for Ebola Emergency Response (UNMEER), last week. We need ‘more staff to be deployed to the districts where the disease is. We need more Ebola treatment facilities, more community care centres, more partners on the ground to staff these centres, we need greater mobility. And we need money to pay for it all.’

So it was not much to ask that the world’s most powerful leaders would seize the opportunity of the G20 Summit in Australia (15-16 November) to address the acute global health and humanitarian crisis of Ebola.

Some governments have already made generous pledges of finance and medical staff since the WHO declared this Ebola outbreak a ‘Public Health Emergency of Global Concern’ in August this year. Yet instead of ambitious new commitments to help implement the UN plan, the G20 issued a statement on Ebola that was more talk than action.

Yes, G20 countries want to ‘extinguish’ the outbreak, and will ‘do the necessary,’ but no new cash or human resources were pledged. Their statement seemed to back away from specific commitments from governments; it could only ‘invite’ other governments to respond, whereas it ‘urges’ the pharmaceutical sector, the World Bank and IMF to do so.

There is one apparently new commitment in the statement: a further $300m from the IMF, with an unspecified split between concessional loans, debt relief, and grants. This is in the context, however, of the combined debt of Sierra Leone, Liberia and Guinea being $3.6bn, which is already costing them $100m in debt service in 2014, and will be more next year. Considering the devastating impact of Ebola, these countries need grants and debt cancellation, not new debt.

To be fair, the G20 statement is a little better on solutions for the longer-term. The G20 recommitted to implementing the WHO’s International Health Regulations (which they are legally obliged to have already completed by 2012), that focus on disease surveillance and response capacities. The statement flagged that some G20 countries have initiatives to support countries in West Africa and elsewhere to implement the regulations too.

The World Bank re-announced its idea to develop a contingency fund for health crises, which would provide ready cash in the event of a future outbreak. The fund is supposed to provide a financial incentive for pharmaceutical companies to invest in vaccines and treatments for diseases afflicting developing countries, by assuring them that any vaccine or drug that they produce be paid for (out of this fund) if another epidemic hits. Clearly global financing for rapid response to outbreaks could be a useful vehicle for global actions. However, such solutions must also enhance local capacity to respond to outbreaks, and rapidly mobilise sufficient human and financial resources to help the countries in need.

The Ebola crisis highlights the failure of the current research and development (R&D) system which relies on market incentives for developing vaccines and medicines for public health needs. Financing R&D for vaccines and medicines for Ebola and similar outbreaks needs to happen now. R&D cannot wait till an outbreak is declared a global emergency. Instead the vaccines and medicines must be developed, and be ready for production and distribution at that time.

We will await the details of those proposals. The immediate priority must be focusing on the current outbreak, where there is still a need for greater international response. The UN has set itself a target to get a hold on the epidemic by 1 December – which would require treating 70 per cent of patients, and ensuring that 70 per cent of all burials are done safely. We are now 13 days away from this deadline, and the G20 had an opportunity to push the international response towards this goal. Unfortunately, it didn’t take it.

There is still a long way to go to turn this epidemic around, to reduce suffering and to save lives. This crisis cannot be summarised by numbers of cases and deaths – it is reaching into the heart of these countries, spreading fear and social breakdown. Oxfam is working with people who have lost five members of their family in a single week to Ebola. This kind of devastation is not easily overcome.

The impact also goes far beyond Ebola cases. A major collapse of health services means that deaths and illnesses from other diseases are going unchecked. It is difficult to imagine what can happen to women who have difficult labours when no health service is available for them, or for children that can’t get treated for malaria or pneumonia.

We urge G20 countries to rapidly deliver the promised financial and medical support to the affected countries in order to help bring an end to the suffering of their citizens.

The G20 has missed an important opportunity in the fight against Ebola. Now they have 13 days to prove they can still be world leaders.

 

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EBOLA AND WHO REFORM: WHO CARES? By Charles Clift, Senior Consulting Fellow, Centre on Global Health Security, Chatham House

The ongoing Ebola story has highlighted the importance of the World Health Organization (WHO) in coordinating international action to combat emerging infectious disease threats. But it has also revealed the deficiencies in its performance which have now allowed a disease outbreak in West Africa to turn into a major international emergency. But in the current crisis in West Africa blame for its performance has been more prevalent than praise. As even its senior officials now admit WHO was too slow to recognize the potential seriousness of the outbreak – while also blaming the cutbacks in its emergency response capability agreed by its member states, as well as the unusual nature of the outbreak which it says caught the international community as a whole on the hop. The officials also point out that WHO is a technical assistance agency: there to help and advise governments on how to respond and supply needed expertise rather than run emergency healthcare operations on its own account.

On the other hand, some NGOs such as MSF, working to combat Ebola on the frontline, have criticized WHO’s slow response. They say that it should have recognized much earlier than it did the need to take the lead in mobilizing funding and personnel from other international actors to strengthen the weak healthcare infrastructures in the affected countries, as well as intensifying its own efforts to support governments with technical assistance and expertise.

Others blame WHO’s slowness and lack of leadership on its fundamental structural problems, which the reform programme launched by Margaret Chan in 2010 was intended to address. These structural problems include both its funding and its unique structure of regional offices which elect their own leaders. Much adverse comment has been directed at the role of WHO’s Africa regional office in Brazzaville which Peter Piot recently described as being staffed with political appointees rather than the most capable people, and the alleged lack of good cooperation between Brazzaville and Geneva. While there is undoubtedly financial stringency in WHO, and a severe shortage of experienced staff in HQ, the case is different with country staffing. The three most affected countries have country office staff exceeding 100 in total, there are nearly 750 in the country offices in the West African region as a whole, and there is nearly 600 staff in the regional headquarters in the Congo. In addition the African region has nearly 2500 contracted staff involved in polio eradication. It is hard to believe that more could not have been done with all these staff on the ground if properly mobilized and managed.

A report on WHO reform published in May this year, based on the deliberations of a working group convened by Chatham House, noted that WHO’s core functions as defined by WHO excluded explicit reference to promoting and maintaining global health security, specifically including its response to disease outbreaks and public health emergencies.

But the report focused mainly on the WHO’s structural problems that the ongoing internal reform process in WHO was not dealing with. The Ebola story illustrates many of these. The report asked: whether WHO really needed six semi-autonomous regional offices? Was this not a recipe for conflict and slow and poor decision-making? And did it need 150 country offices? How did politicization and the politics of patronage adversely affect WHO’s performance, credibility and effectiveness at all three levels of the organization? Was its complex governance structure not the main reason that it spends one third of its budget on administration and management at the expense of its technical programmes? Were there not more efficient ways to do what WHO needed to do? Why was WHO often reluctant to lead rather than to follow its member states? Why did the member states countenance this state of affairs?

The report has evoked practically no response at all – from governments, the academic community, NGOs or anyone else for that matter. Why is this?

A plausible explanation, which was suggested often by one of the members of the Chatham House working group, is that no one cares sufficiently about WHO reform to do anything about it. The status quo is too comfortable, or not sufficiently uncomfortable, for any member state to want to change things.

The weird financing arrangements, whereby 75% or more of WHO’s income is in the form of voluntary contributions, suits member states for different reasons. A few rich countries (and charities such as the Bill and Melinda Gates Foundation), by directing their voluntary contributions in ways of their own choosing, get to control what WHO does in spite of being a small minority in the World Health Assembly, or not in it at all. Yet because of this effective subsidy, poorer countries pay contributions which are a quarter of what they would be if WHO was wholly financed by member state subscriptions. Thus for the great majority of member states WHO membership is a bargain. They get a WHO country office whose budget (paid for by WHO) will normally exceed by a large margin their WHO contribution.

Because WHO regional offices are run as semi-autonomous replicas of WHO in Geneva, ministries of health also get the opportunity to influence appointments to regional and country offices where those chosen can access UN-related salary and benefit packages. Thus it is not just a financial bargain but often carries actual or personal benefits for senior country officials. So there is little mystery about why change should be resisted. Even where it is recognized that a WHO country office may have outlived its utility (in a country like Thailand for instance) it would be a brave politician or official who suggested closing what is essentially a free gift from the international community.

So no mystery there. The non-response of the ‘public interest’ NGO movement is more puzzling on the face of it. But perhaps the answer is not totally dissimilar. These NGOs have no financial stake in WHO and therefore no direct influence on its governance. Many regard the WHO as a forum where they may express their views and the annual World Health Assembly as a perfect gathering of notables in the global health community to pursue advocacy and influence member state delegates. While NGOs may be critical of the WHO, as in the case of Ebola, they also hold it in great esteem as the one international organization with the responsibility of striving for “the attainment by all peoples of the highest possible level of health”. The NGO mindset is therefore to seek to defend this noble objective and, in particular, protect it from political and commercial pressures which are seen as a threat to this mission.

Moreover the WHO secretariat is generally regarded as providing objective technical leadership and support to member states in a world dominated by governments and corporations whose motivations and interests may run counter to health objectives. For that reason NGOs are generally only likely to be critical of the WHO secretariat if it appears to be supine in its dealings with commercial stakeholders, or with governments deemed to be unduly influenced by commercial rather than public health interests.

At the same time NGOs, notably Oxfam, have campaigned actively for member states to increase their secure funding of WHO to protect its core functions, such as those which support enhanced access to essential medicines. But member states have to date paid little heed.

So it seems that the political preconditions for fundamental reforms of WHO funding and governance are absent. Nevertheless the world badly needs a global body that can take on a leadership role in global health policies and help control disease outbreaks before they turn into international crises. The panic engendered by the Ebola crisis should result in a reality check for all concerned. The WHO reform process, begun 4 years ago, does not seem to be on course to deliver a WHO that can be relied upon as fit for purpose.

 

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Ebola: Some thoughts from my time in Liberia By John Spray, ODI Fellow, Ministry of Commerce and Industry, Liberia.

 

A lot has been written about the Ebola crisis in West Africa in the last few weeks. Many excellent articles have highlighted the plight of those suffering with Ebola (Newsweek), and the people on the frontline trying to tackle the virus (Time) and the consequences on the affected countries as a whole (How we made it in Africa). However, the real tragedy is how an inherently preventable virus was able to spread like wildfire throughout West Africa and why public health facilities failed on such an enormous scale.

I first heard about Ebola in March 2013, four months after the first patient died of the virus in a small village in south-eastern Guinea, the first ever in West Africa.
With the death toll rising across the border in Guinea, discussions in Monrovia turned to the threat of it reaching the capital: “no previous outbreak has killed more than 300 people”, “it is easy to avoid just don’t go near sick people and you are safe”, and “the disease kills people so quickly it will die out before it reaches Monrovia”. The general message was “it is scary, but we can control it with basic public health.”

Despite these reassurances, everyday you check the news: how many infected? How many died? How many health clinics were beginning to shut due to healthcare workers leaving their posts? Despite the growing chaos, we in Monrovia continued to rationalize the situation. We knew things were getting worse but we didn’t act in time.

So when did it get “out of control”? Was it when MSF declared it to be so in June? Was it when the virus hit Conakry, Freetown and Monrovia, making control of the disease in crowded urban environment increasingly hard? Perhaps it was when the Liberian-American Ministry of Finance consultant died after flying to Lagos, inadvertently putting a planeload of passengers and Africa’s most populous country at risk.

Whenever it was, there is no question that we are now in the middle of an unprecedented crisis. Every day, I dread reading the news. The front page of every newspaper is full of articles discussing the bleak picture of Liberia’s largest slum quarantined like something out of a science fiction novel. I read about the almost complete collapse of the government’s health care facilities and the justifiable fear of the healthcare workers too scared to go to work. We hear terrifying stories of suspected cases being turned away from treatment centres because there is no space to treat them, and bodies left on the street for days without someone coming to pick them up. Most of all, I fear for the secondary threats should countries follow through on plans to impose economic embargoes on the country.

Already five airlines have stopped flying to Liberia through fear of the disease. Earlier reports that West African ports have refused entry to vessels which have docked in Liberia appear false, but raise an alarming prospect of the country cut off from essential imports. This is dangerous given that Liberia is completely dependent on imports with an import bill equal to 60 percent of GDP including two of the most important commodities, fuel and rice. Even without an economic blockade importers are worried.

Early reports suggest for the last four weeks the number of import certificates are down 30 percent from the previous year. Not to mention, the travel restrictions inside the country making movement of agricultural goods from farm to market next to impossible. These developments will raise the price of essential goods necessary for the Liberian economy to function and will harm the very poorest. They also raise the possibility of riots on the street and a return to the days of anarchy last seen during Liberia’s bloody civil war.

So how did this happen? The underlying causes of this outbreak are many and difficult and will be discussed for years to come. Fundamentally, they focus on the fragility of West African states and the failure of emergency planning to tackle the crisis when it was at a manageable level.
What can we do about it? Despite the fear, there are many brave West Africans and foreigners continuing to fight this disease. The Ministry of Health is working to open new treatment centres, MSF continues to fight the battle on the front line and are managing patient care alongside national governments. The World Bank has promised USD200million to fight the disease in West Africa. The African Development Bank has promised USD210million to build West African public health facilities. The World Food Program has begun the process of bringing in food to tackle the secondary crisis. NGOs on the ground, including Oxfam, have begun gearing up awareness campaigns to get the message out that Ebola is preventable. These things are vital to the immediate fight and the world needs to react, and react fast.

Once the immediate crisis is brought under control, we must consider measures to strengthen the state institutions especially the health service in order to effectively deal with health threats in the region.

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni