Against the backdrop of the unfolding coronavirus outbreak, the World Health Organisation held its annual executive board meeting last month and made new commitments to highlight attacks on healthcare workers, encourage governments to better prepare for health emergencies, and re-evaluate its global alert system.
As governments around the world scramble to contain and/or prepare for outbreaks of the Covid-19 virus, and as health systems in China, South Korea, Italy, Iran, and other nations come under immense strain, this briefing looks at the emergency-related topics the WHO board discussed.
Gathering in early February, the 34-member board identified issues to be addressed later in the year at the group’s decision-making session, the World Health Assembly.
Nearly 80 percent of high-impact epidemics now take place in fragile, conflict, or vulnerable settings, aligning the footprint of disease and the footprint of conflict, Dr. Mike Ryan, executive director of the WHO’s Health Emergencies Programme, told a session on health emergencies. “We have to reflect on our capacities to operate in those deep-field environments safely,” he added.
In the Democratic Republic of Congo, for instance, the WHO not only oversees the response to the Ebola outbreak in the eastern provinces – where militia attacks are ongoing – but it also provides healthcare to millions of civilians displaced by conflict elsewhere in the country. In 2019, it also undertook vaccination campaigns against measles and cholera.
More than 1,600 “security incidents” took place in DRC alone in 2019, of which 60 percent were related to armed conflict and crimes, said Dr. Ibrahima Socé Fall, the WHO’s assistant director-general for emergency response. Attacks on healthcare facilities and staff killed at least five Ebola response workers in DRC in 2019.
WHO officials told board members that conflict, the impacts of climate change and urbanisation, and attacks on health workers are all increasingly frustrating efforts to respond to health needs in emergency situations worldwide, as concerns mount over “the scale and magnitude of simultaneously occurring crises”.
The WHO said it responded to 51 public health emergencies last year in more than 40 countries. These included emergencies classified at the highest grade – such as the Ebola outbreak or responding to needs in Yemen and Syria – as well as lower-graded emergencies.
According to a report released late last year by WHO Director-General Tedros Adhanom Ghebreyesus, other challenges included: movements of large numbers of people; ongoing insecurity; limited access and staff; and escalating field costs.
Here’s a more detailed look at four key issues brought up at the meeting.
Publicising attacks against health workers
Speaking at the meeting, Tedros recalled the deaths of healthcare workers in DRC last year. “They were killed in cold blood while saving lives,” he said. “They were facing Ebola, and they were facing bullets – so bullets killed them.”
Nearly 800 attacks against health workers and facilities took place worldwide in the first nine months of last year, killing 171 people, according to the UN.
The board agreed that WHO members will take up a resolution at the World Health Assembly in May to address attacks on healthcare workers.
The resolution expresses alarm about the increasing attacks on medical personnel and facilities around the world, and the resulting lack of access to medical services as a consequence of these attacks. It also requests regular reports to the World Health Assembly on attacks against workers and facilities in complex humanitarian emergencies.
“They were facing Ebola, and they were facing bullets.”
In 2012, the WHO was asked by member countries to collect and report information on attacks against healthcare workers and facilities. As a result, the Surveillance System for Attacks on healthcare (SSA) was established to collect and share data on attacks on health facilities, health workers, health transport, and patients in complex humanitarian emergencies.
Reform of global alert rules?
The WHO’s International Health Regulations (IHR) are at the heart of how the organisation responds to health emergencies that can jump borders. These are even more sharply in focus now due to the spread of coronavirus. The regulations include guidelines on issuing a Public Health Emergency of International Concern, or PHEIC. (Novel Coronavirus was first recorded at the end of December 2019 and was declared a PHEIC on 30 January, 2020.)
In principle, the IHR regulations seek to address the international spread of diseases without unnecessary interference in international traffic and trade. In effect, governments seem to often regard PHEICs as a deterrent to both.
The rules govern areas such as state surveillance requirements and obligations to notify the WHO regarding potential public health threats. States are required to develop capacities including legislation and policy, coordination, surveillance, response preparedness, risk communication, human resources, and laboratory capacities.
In the midst of the coronavirus outbreak, governments and health officials have called for reforms to these regulations, to improve preparedness for and response to emergencies.
Many countries, for instance, have enforced travel restrictions in response to the coronavirus that go against the letter of these rules. On the other end of the spectrum, West African countries were late in reporting Ebola in 2014 and governments ignored WHO recommendations not to impose travel and trade restrictions.
The goal is to establish an intermediate level of alert that would be a step before a PHEIC and could signal the need to prepare for a potentially serious outbreak and how to respond responsibly in the current situation.
WHO officials said they are working on a system to go beyond the current “binary” option of either declaring a PHEIC or refraining from issuing one. A group of experts is now designing an intermediate level of alert, the officials informed the board.
The power of preparedness
Climate change, urbanisation, and intensification of civil conflicts are increasing the frequency and severity of emergencies with health consequences, WHO officials told board members.
There are efforts “to bring preparedness to the centre of the agenda”, a senior WHO official said, describing a focus of the week-long board meeting that resulted in a draft resolution: Strengthening Preparedness for Health Emergencies; Implementation of International Health Regulations. The draft resolution seeks to improve preparedness for emergencies at the national and international level by prescribing measures for UN and WHO member states.
The United States disassociated itself from a provision that included language on providing care for “sexual and reproductive health, and maternal, newborn and child health” in emergencies.
The WHO describes emergency preparedness as a combination of “the knowledge and capacities and organisational systems developed by governments, response and recovery organisations, communities and individuals to effectively anticipate, respond to, and recover from the impacts of likely, imminent, emerging, or current emergencies.”
Climate change, urbanisation, and intensification of civil conflicts are increasing the frequency and severity of emergencies with health consequences.
In the context of the international health regulations, “preparedness includes the development of national, intermediate and community/primary response level public health emergency response plans for relevant biological, chemical, radiological and nuclear hazards,” it says.
In real terms this means: mapping potential hazards and hazard sites; identifying available resources and assembling appropriate stockpiles; and ensuring personnel are trained to support operations during a public health emergency.
The draft resolution calls for countries and the WHO to work with the UN secretary-general and the UN’s emergency aid coordination body, OCHA, to: strengthen coordination; review preparedness and response strategies; and increase collaboration between relevant actors to accelerate preparedness for pandemics and disease outbreaks – in particular in fragile situations and conflict-affected areas.
WHO’s Ryan said that preparedness has no future without fundamentally broadening accountability and looking for solutions beyond the health sector, including from organisations with expertise in water, sanitation, urbanisation and vector control. He stressed the importance of partnerships at all levels.
WHO recently established its first dedicated team on preparedness, led by Dr. Jaouad Mahjour, assistant director-general for emergency preparedness and international health regulations.
Finding the funding
Insufficient funding for emergencies was also noted at the meeting.
Last month, the WHO requested an additional $40 million for the Ebola response in DRC. It also launched an appeal for $675 million to fund coronavirus response efforts. Over the past few weeks, a raft of countries (many European nations, Canada, Japan, and Kuwait) and other actors (the Bill and Melinda Gates Foundation, Vital Strategies, and Resolve to Save Lives) have injected funds, the WHO has said. In the latest financial move, UN relief chief Mark Lowcock released $15 million from the UN’s Central Emergency Response Fund (CERF) on 1 March to help fund global efforts to contain the Covid-19 virus.
The Contingency Fund for Emergencies (CFE) is one of the main ways in which the WHO funds its work to fight outbreaks.
Established in 2015, it enables the WHO to respond immediately to disease outbreaks and humanitarian crises with health consequences. This mechanism can release funds (in an initial tranche of up to $500,000) within 24 hours of an emergency request. Other kinds of financing have different funding criteria and slower disbursement cycles. In addition, since contributions to the fund are flexible – instead of being earmarked for specific activities – it enables the WHO “to rapidly fund the initial response to the broadest possible range of health emergencies”.
In his statements during the meeting, Ryan said the CFE had disbursed $83 million across 21 countries for 22 events in 2019 including 12 diseases outbreaks, six natural disasters, and four complex emergencies. Ten million dollars had been disbursed from the fund to fight the coronavirus outbreak, he added.
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