Global Health-CS1

DEBATE Open Access

The Ebola Outbreak: Catalyzing a “Shift” in Global Health Governance? Tim K. Mackey1,2,3

Abstract

Background: As the 2014 Ebola virus disease outbreak (EVD) transitions to its post-endemic phase, its impact on the future of global public health, particularly the World Health Organization (WHO), is the subject of continued debate. Criticism of WHO’s performance grew louder in the outbreak’s wake, placing this international health UN- specialized agency in the difficult position of navigating a complex series of reform recommendations put forth by different stakeholders. Decisions on WHO governance reform and the broader role of the United Nations could very well shape the future landscape of 21st century global health and how the international community responds to health emergencies.

Discussion: In order to better understand the implications of the EVD outbreak on global health and infectious disease governance, this debate article critically examines a series of reports issued by four high-level commissions/ panels convened to specifically assess WHO’s performance post-Ebola. Collectively, these recommendations add increasing complexity to the urgent need for WHO reform, a process that the agency must carry out in order to maintain its legitimacy. Proposals that garnered strong support included the formation of an independent WHO Centre for Emergency Preparedness and Response, the urgent need to increase WHO infectious disease funding and capacity, and establishing better operational and policy coordination between WHO, UN agencies, and other global health partners. The recommendations also raise more fundamental questions about restructuring the global health architecture, and whether the UN should play a more active role in global health governance.

Summary: Despite the need for a fully modernized WHO, reform proposals recently announced by WHO fail to achieve the “evolution” in global health governance needed in order to ensure that global society is adequately protected against the multifaceted and increasingly complex nature of modern public health emergencies. Instead, the lasting legacy of the EVD outbreak may be its foreshadowing of a governance “shift” in formal sharing of the complex responsibilities of global health, health security, outbreak response, and managing health emergencies to other international structures, most notably the United Nations. Only time will tell if the legacy of EVD will include a WHO that has the full support of the international community and is capable of leading human society in this brave new era of the globalization of infectious diseases.

Keywords: Ebola virus disease, Global health governance, WHO reform, International Health Regulations, Global health security agenda

Correspondence: [email protected] 1Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA 2Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA, USA Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Mackey BMC Infectious Diseases (2016) 16:699 DOI 10.1186/s12879-016-2016-y

Background In January 2016, the World Health Organization (WHO) declared that the devastating 2014 Ebola virus disease (EVD) outbreak in West Africa was finally coming to an end and in March officially announced it was no longer a public health emergency [1]. These developments came after nearly three years of unprecedented inter- national cooperation to combat the largest Ebola out- break in history, one that has claimed the lives of over 11,000 people and wrought social and economic devas- tation to Liberia, Sierra Leone, and Guinea, the three countries most heavily impacted. Re-emergence of EVD through detection of new case clusters after countries had been declared “Ebola Free” by WHO have also per- sonified the enduring risks and resilience of the disease [2, 3]. Despite these setbacks, the possibility of a wide- spread EVD pandemic is now much farther in the dis- tance as the outbreak transitions to its post-endemic phase. International efforts to finally put an end to this devastating chapter of Ebola instead focus on ongoing concerns of treating survivors and averting any potential further transmission, while exercising vigilance in sur- veillance, prevention, and maintaining response capacity. Importantly, the EVD outbreak also marks a sentinel

event in global public health, one that arguably requires a “shift” in how we approach governance for global health. Yet, the full repercussions of the outbreak on the future of historic international health institutions, such as the WHO, are only now starting to take shape. Hence, this piece provides a summary of the current international debate and discourse on global health gov- ernance reform measures post-EVD, focusing on the WHO and the future role of the United Nations in the broader global health architecture. This is accomplished by examining a series of reports issued by four high- level commissions/panels convened to specifically assess WHO’s performance and broader governance reform post-EVD. This includes recommendations from the WHO Interim Assessment panel established by the WHO Executive Board (Interim Panel); an external inde- pendent panel jointly convened by the Harvard Global Health Institute-London School of Hygiene & Tropical Medicine (“Harvard-LSHTM panel” comprised of mem- bers from academia, think tanks and civil society); the Commission on a Global Health Risk Framework for the Future (CGHRF) convened by the U.S. National Acad- emy of Medicine (formerly the Institute of Medicine); and a separate High-Level Panel on the Global Response to Health Crises appointed by UN-Secretary General Ban Ki-moon (Kikwete Panel). It then discusses recent actions taken by WHO in response to calls for reform and also provides a critical assessment of how global health governance needs to “evolve” in order to modernize for the 21st century.

Discussion Is the “Evolution” of Global Health Governance Underway? Influenza viruses evolve in two different ways including antigenic “drift” (e.g. small genetic mutations occurring continuously over time) and “shift” (e.g. major, abrupt changes/reassortment leading to different virus subtypes with high virulence and pandemic potential) [4]. This evolutionary process presents significant challenges in developing therapeutics and vaccines, as well as respond- ing with appropriate public health measures, as viruses adapt to their environment and traverse multiple animal and human hosts. Similar to the “drift” that occurs in viral evolution, previous disease outbreaks of SARS (2002), H1N1/A (2009), MERS-CoV (2013), and the ever-looming threat of highly pathogenic influenza (e.g. H5N1), precipi- tated the current crisis in global health governance now occurring post-EVD [5–8]. Criticism has been swift, in- cluding strong statements from several heads of state, key civil society actors, national governments, and academia, opining on the need to pursue more radical reform mea- sures, primarily focused on the future of WHO [9–13]. These developments could mark the beginnings of a “shift” in the evolution of global health governance.

Pre-Ebola reform Calls to reform WHO are not new, but have grown in- cessantly louder in the wake of EVD [13, 14]. As the international public health agency charged with “the at- tainment by all people of the highest possible level of health”, WHO has faced many hurdles over the past two decades [15, 16]. Many of WHO’s challenges can be at- tributed to persistent budget limitations that have led to cuts in funding/staff and reallocation of resources from normative functions to discretionary programs highly influenced by donors [5, 6, 17]. Additional challenges arise from changing programmatic and Member State priorities, the formation of new global health initiatives (e.g. UNAIDS, GAVI, the Vaccine Alliance, PEPFAR, Stop TB Partnerships, and The Global Fund to Fight AIDS, Tuberculosis and Malaria) that often maintain parallel health systems and bypass traditional inter- national governance structures, the rise of alternative channels/mechanisms of funding, and political inaction by Member States to pursue needed reforms identified as early as the 1990s [5, 6, 14–16, 18]. Previous international public health emergencies have

also foreshadowed governance challenges that WHO would be forced to confront during the EVD outbreak. Specifically, the 2002 SARS outbreak, a novel corona- virus that spread to more than two dozen countries, marked a paradigm shift ushering in a new era of the globalized pathogen and demanded a modernization of WHO governance instruments and outbreak response

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processes [19, 20]. Though generally viewed as well man- aged due to an unprecedented international response co- ordinated by WHO and its Global Outbreak Alert and Response Network (GOARN), the SARS outbreak never- theless exposed certain weaknesses [21]. Challenges in- cluded countries failing to report the threat of a potential outbreak with international implications, lack of sufficient “global” surveillance capacity, conflict between economic and trade considerations in public health emergencies, and global politics hindering WHO assistance [19, 21–24]. Most importantly, SARS also made it clear that the

WHO’s International Health Regulations (IHR) were in need of an urgent update, leading to its revision in 2005, which required Member States to commit to minimum core public health systems, including surveillance, la- boratory capacity, and emergency response capabilities [19, 25, 26]. The revision also granted WHO expanded authority by requiring Member States to proactively re- port potential international disease events and giving WHO the power to declare a “public health emergency of international concern” (PHEIC.) It also charged the agency with the difficult duty of balancing competing in- terests of trade, travel, human rights, and public health measures [19]. Fast forward to August 2014, when WHO issued its third-ever PHEIC for the EVD out- break, and many of these challenges would “re-emerge” despite efforts to address them in the 2005 IHR revision. Though a revision to the IHR was an important step

post-SARS, more fundamental reform measures to ad- dress limitations associated with WHO’s governance and organizational structure have not been carried out as successfully. Proposals on how to pursue WHO reform post-SARS and pre-EVD have differed widely in scope and strategy. This includes reform proposals that have been structural, such as forming a new “Committee C” to engage a broader set of stakeholders (including civil society organizations); creating a “World Health Forum” for non-state actor engagement (a proposal rejected by

Member States and criticized by civil society actors); split- ting WHO into two separate technical and political entities; revising WHO’s constitution; and reforming WHO’s decentralized regional structure [6, 27–30]. Other re- forms have focused on operational and financial aspects of WHO including: ensuring more sustainable operational fi- nancing by abolishing the zero-nominal growth require- ment for member state contributions; allowing WHO to practice currency hedging, and establishing an ‘emergency fund’ [10, 31–33]. Still others have argued for additional powers/authority for WHO including: empowering WHO with additional normative "soft" and "hard" law instruments (e.g. 'Framework Convention on Global Health';) and complete "reinvention" of WHO's mandate, powers, and structures (see summary in Table 1) [10, 15, 34]. Though the WHO reform process has been ongoing

for decades crossing the tenure of several past WHO Director Generals, the formal reform process carried out by WHO immediately proceeding the EVD outbreak was limited in scope, primarily focused on incremental in- ternal governance changes [14]. These included: reasses- sing future financing of WHO, setting the organization’s priorities in health, cutting its budget, drafting a framework for engagement with non-state actors, and implementation of other internal governance, program- matic, evaluation, accountability, and managerial reform measures [14, 35].

Post-Ebola reform Post-EVD, WHO’s future is now at a critical juncture, as widespread criticism of WHO’s handling of the EVD outbreak has exposed fundamental weaknesses in the specialized agency’s ability to lead, coordinate, and mobilize an effective international response to the threat of a pandemic. With the stakes never higher, the urgency for WHO reform has been accelerated and is influenced by a collection of recommendations from four high-level

Table 1 Select WHO reform recommendations in the literature pre-EVD

Governance proposal Description Citation(s)

Committee C Establishment of a new “Committee C” of WHA to debate major health initiatives and engage and coordinate across a broader array of global health stakeholders (including non-state actors.)

Silberschmidt G, Matheson D, Kickbusch I. Creating a committee C of the World Health Assembly. Lancet. 2008 May 3; 371(9623):1483–6. [27]

World Health Forum Establishment of a new informal multistakeholder forum to engage non-state actors. This proposal was subsequently rejected by member states and also criticized by civil society actors

Commentary: Hawkes N. Re: “Irrelevant” WHO outpaced by younger rivals. BMJ 2015; 343(aug09 1):d5012–2. WHO website: http:// www.who.int/dg/reform/en_who_reform_world_health_forum.pdf [28]

Splitting WHO Dividing WHO secretariat functions into two different technical and political stewardship entities, with collaboration in areas that overlap.

Hoffman SJ, Rottingen J-A. Split WHO in two: strengthening political decision-making and securing independent scientific advice. Public Health 2014; 128(2):188–94. [6]

Revising WHO’s Constitution

Revising WHO’s constitution to fill the gaps in global governance as part of WHO reform process and for broader democratization of the agency.

Hoffman SJ, Rottingen J-A. Dark Sides of the Proposed Framework Convention on Global Health’s Many Virtues: A Systematic Review and Critical Analysis”. Health & Human Rights Journal 15(1): 117–134. [29]

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panels/commissions that examined WHO’s performance during the EVD outbreak [13, 36, 37]. These include rec- ommendations from the Interim Panel, the Harvard- LSHTM panel, the CGHRF, and the Kikwete Panel, which were reviewed and compared for: (1) proposals specifically addressing internal governance reforms or new mechanisms within WHO’s structure (not including reform proposals specific to the functioning of IHR, which deserve separate in-depth discussion); and (2) proposals focused on involvement and/or coordination from the United Nations on global health and health emergency activities (see summary of characteristics of Panels in Table 2). The first group to issue its recommendations was the

WHO Interim panel comprised of independent experts appointed by WHO, who at the May 2015 68th World Health Assembly (WHA) delivered a report stating that the agency lacked the “capacity or organizational cul- ture” to respond to emergency public health events [38]. The Interim Panel also concluded that WHO managed the crisis by prioritizing “good diplomacy” over neces- sary action, but offered no alternative to WHO, arguing instead that the agency should continue in its central role as the world’s lead health emergency response agency [38]. The panel recommended a set of reforms largely aimed at re-establishing WHO’s central role in health emergencies by advocating for: (a) strengthening of the IHR; (b) establishing a contingency fund for out- break response; (c) formation of an independent Centre for Emergency Preparedness and Response (housed within WHO but overseen independently); (d) support for a WHO plan to develop a global health emergency workforce; and (e) WHO playing a more central role in R&D efforts for future health emergencies [38]. It also recommended the UN Secretary-General consider the

appointment of a Special Representative or Special Envoy aimed at garnering greater political and financial support during a global health crisis, but did not recom- mend establishment of a permanent UN structure/mis- sion. Importantly, many of these core proposals would set the framework for similar proposals expanded upon and carried forward by the other panels. In November 2015, the Harvard-LSHTM panel pub-

lished a set of 10 recommendations in the Lancet, which included several governance reform measures far more expansive than the first set of recommendations made by the Interim Panel. Reforms cover broader areas of global health governance and also include specific re- form measures for WHO, all of which are grouped into four thematic areas of preventing, responding, conduct- ing research, and governing the broader global system for disease outbreaks [39]. Reforms specific to WHO in- cluded: (a) creating a WHO dedicated independent centre for outbreak response; (b) formation of a politic- ally insulated WHO Standing Emergency Committee for PHEIC declaration; (c) investing and strengthening glo- bal capacity to rapidly respond to outbreaks; (d) carrying out time-bound reforms to refocus and streamline WHO; (e) having WHO convene global stakeholders to develop a framework of norms and rules and a global fi- nancing facility for R&D relevant to disease outbreaks; and (f) instituting internal good governance reforms in exchange for more sustainable funding [39]. Broadly speaking the Harvard-LSHTM panel calls for more ac- tive engagement by WHO with the greater global com- munity in managing infectious disease outbreaks, while also recommending that the agency scale back oper- ational activities and instead focus on certain core func- tions [39]. Importantly, the panel also took the step of recommending the establishment of two structures by

Table 2 Characteristics of EVD High-level panels and commissions

Panel/commission name Entity Number of members/ recommendations

WHO Interim Assessment Panel Established by WHO Executive Board comprised of mix of independent experts -Date issued: May 2015 −5 members −21 recommendations

Harvard-LSHTM Panel Establishment by Harvard Global Health Institute and London School of Hygiene & Tropical Medicine primarily from academia, foundations, think tanks, and NGOs

-Date issued: November 2015 −22 members −10 recommendations

CGHR Established as an independent commission with National Academy of Medicine as secretariat funded by foundations and agencies. Commission comprised of members from different countries, foundations, and entities.

-Date issued: January 2016 −17 members −26 recommendations

Kikwete Panel Established by UN Secretary General comprised of political representatives of member states

-Date issued: January 2016 −6 members −27 recommendations

WHO Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies

Established by the WHO Director General to offer guidance on the organization’s emergency reform process. Group chaired by UN SG Special Envoy on Ebola and various members from UN agencies, NGOs, representatives of government health agencies, and others.

-Date issued: January 2016 −19 members −9 core recommendations in its second report

Note: Julio Frenk served on both the WHO Interim Panel and the CGHR. Lawrence Gostin and Gabriel Leung served on both the Harvard-LSHTM panel and CGHR

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the UN Security Council: an Accountability Commission and a Global Health Committee that would independ- ently assess outbreak response and elevate political attention to international health threats [39]. A few months later in January 2016, the CGHRF is-

sued its own comprehensive report with an even more expansive list of 26 recommendations aimed at serving as a broader framework to address the “neglected” threat of infectious-disease crises. Recommendations were cat- egorized under four domains of investment, building public health capabilities, strengthening surveillance, and accelerating R&D for pandemics [40]. Ten of these recommendations are specific to WHO, with some mir- roring previous recommendations by the Interim and Harvard-LSHTM panels (e.g. formation of an independent Center funded by increased member state contributions, establishment of a contingency fund, and strengthening of the IHR.) [41]. The CGHRF generally advocated for strengthening WHO’s capacity to lead in pandemic pre- paredness and response by further reinforcing previous recommendation to create a WHO Center for Health Emergency Preparedness and Response, though independ- ently overseen by a Technical Governing Board [41]. It also called for the involvement of the World Bank and International Monetary Fund (IMF) to help finance and strengthen implementation of IHR core capacities. Add- itionally, the CGHRF called for WHO to actively engage in other proposed governance structures that would oversee acceleration of R&D for pandemic preparedness and response (including the establishment of an inde- pendent Pandemic Product Development Committee) [41]. Finally, though the CGHRF report advocates for enhanced cooperation between WHO and regional, sub-regional, national governments, and non-state ac- tors, it does not directly call for a UN leadership role, other than in the context of developing strategies for sustaining health systems capacity in fragile/failed states and during times of war. Shortly thereafter, at the end of January 2016, the

Kikwete Panel finalized its own report titled “Protecting Humanity from Future Health Crises”, recommending a final set of 27 measures to avert a future global pan- demic, specifically noting that the risk of a highly patho- genic influenza virus was a chief concern [42]. Recommendations from the panel carry on similar themes to prior panel recommendations and are grouped into national, regional/sub-regional, and international-level recommendations, as well as sub- themes of development and health, R&D, financing, and follow-up and implementation recommendations. Chief among them included forming a Centre for Emergency Preparedness and Response within WHO, advancing full implementation of the IHR, securing appropriate finan- cing for the WHO Centre and IHR compliance, and

having WHO oversee the establishment of a fund and priority list to support R&D for neglected communicable diseases [42]. In addition, the panel strongly emphasized the need for a clear line of command within the UN sys- tem to coordinate a global response to a health and hu- manitarian emergency and more bodly recommended the establishment of a High-level Council on Global Public Health Crises housed within the UN General As- sembly [42]. Similar to the Interim Panel and CGHRF, the Kikwete Panel offered its strong endorsement of WHO as the “single” global health leader, but also noted that should the WHO fail to successfully reform or be empow- ered by its member states, that an “alternate” UN institu- tional response mechanism(s) might be necessary [42]. Collectively, these review panels, all governed by dif-

ferent stakeholders with varying operational mandates and perspectives, add increasing complexity to the ur- gent need for WHO reform post-EVD that the agency must now navigate (see Table 3 for a summary of reform recommendations summarized into themes of WHO re- form and UN participation.) One proposal that had unanimous support was the formation of a WHO Centre for Emergency Preparedness and Response, which would be independently funded and governed but still housed within WHO [36, 37]. Other reform measures that garnered cross-panel support included the urgent need to increase WHO’s assessed contributions, developing mechanisms to enhance cooperation with non-state ac- tors, strengthening global disease surveillance and IHR core capacities (including creating incentives/disincen- tives for IHR compliance,) and establishing better oper- ational and policy coordination between WHO, UN agencies, and other global health partners [36, 37]. In response, to the myriad of recommendations set

forth, the WHO, its Executive Board and its decision- making body, the WHA, were tasked with how to prioritize reforms, assess the feasibility and resources necessary to carry them out, and determining what re- forms would be agreeable to all of its member states. Complicating this calculus is the fact that WHO’s current governance structure only allows formal par- ticipation by state actors, though the influence of powerful non-state actors (including those who provide the majority of funding to WHO through voluntary contributions) is unlikely to be completely silenced. The emergence of the Zika virus, which was declared a PHEIC event (subsequently removed November 2016), also has the potential to delay and/or significantly alter the pathway of post-EVD WHO reform. The emergence of Zika once again demonstrates that changes needed to ensure WHO can lead in averting the next health crisis are not currently in place [43]. Further, current WHO Director-General Dr. Margaret Chan’s tenure is coming to an end, meaning any long-term reforms will

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likely need to wait until her replacement is elected in 2017 [33, 37, 44].

Conclusions The 2014 EVD outbreak represents the re-emergence of an old and powerful infectious disease foe that has

brought with it new urgency to address unresolved chal- lenges in global health governance. At stake is the very nature and identity of WHO, which is feeling pressure to rediscover its role and relevance in a crowded and com- plex global health landscape populated by powerful nation states, large-scale bilateral health initiatives,

Table 3 Matrix of WHO governance reform recommendations post-EVD

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multistakeholder partnerships, development banks, influ- ential private foundations, and other UN agencies [14, 31, 45, 46]. How WHO will navigate the complexities of re- form recommendations remains uncertain. What is clear is that the WHO needs to modernize in order to adapt to a new century of shared global health security, given on- going threats from the emergence and re-emergence of in- fectious diseases, such as EVD and the Zika virus, and the inevitability of future outbreaks with pandemic potential.

Prologue: reform responses by WHO Despite the need for a revitalized WHO, reforms sup- ported by WHO’s own high-level Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies (WHO Advisory Group, established by the WHO DG in July 2015), whose role was to provide guidance in rela- tion to WHO’s emergency reform process (including the recommendations issued by the various panels), did not recommend some of the major changes advocated by the panels [47]. Instead, at the January 2016 WHO Ex- ecutive Board meeting (coinciding with WHO declaring that EVD was no longer a PHEIC) , the WHO Advisory Group recommended critical enhancements focused on WHO internal outbreak and health emergency manage- ment, but did not recommend larger structural govern- ance changes. Specifically, the group recommended the widely supported establishment of a centrally-managed, separate, dedicated WHO global Programme for Out- breaks and Emergencies headed by an Executive Dir- ector having its own budget and workforce that reports to the WHO DG [36, 47]. WHO would leverage the for- mation of this internal mechanism to also engage in other reform measures including ensuring greater health stakeholder collaboration, establishing better oper- ational/ business processes during outbreaks, calling for an increase in member state assessed contributions for emergencies, capitalizing a contingency fund for emer- gency response, and improving resource mobilization, political engagement, accountability and external over- sight [36, 47]. Following up on the WHO Advisory Group’s recom-

mendations, at the 69th WHA in May 2016, Member States approved a plan formally establishing the WHO Health Emergencies Programme with a structure in many ways identical to that proposed by the WHO Ad- visory Group [48]. Accompanying its formation was an increase of $160 million to the existing WHO programme budget for WHO’s work in health emergen- cies, establishment by the DG of an independent over- sight and advisory body, and the announcement of the appointment of Dr. Peter Salama (formerly with UNICEF) as the inaugural Executive Director [49]. Other reform recommendations that the WHO leader- ship has committed to carrying out or that are in the

process of being implemented include the creation of a global health emergency workforce, strengthening im- plementation and monitoring of IHR core capacities, funding of the $100 million contingency fund for emer- gencies (via voluntary contributions including US$26.60 million received as of May 2016), and the development of an “R&D Blueprint” for accelerating R&D for health emergencies [49, 50]. Specific to the need for greater coordination and accel-

eration of R&D for vaccines, drugs, diagnostics, delivery systems, and other health technologies to avert a future epidemic when no existing medical countermeasures exists, the WHO published its “Plan of Action” for its R&D Blueprint on May 2016 [51]. This document presents the preliminary strategy for the WHO R&D Blueprint, as originally requested at the 68th WHA, and envisions a central convening and coordinating role for WHO in health R&D, a concept supported in different forms by all of the panels [51]. Though the Plan of Ac- tion envisions an inclusive and collaborative global ap- proach to tackle the lack of R&D preparedness and access to treatment made evident during the EVD out- break, it is unclear how this framework will be funded, implemented, and whether it will be aligned with exist- ing governance structures and other related proposals. This includes existing structures such as the UN High- Panel on Access to Medicines and other financing and normative instruments currently being explored (includ- ing the WHO TDR Health Product Research & Develop- ment Fund and a proposed Global biomedical R&D treaty) [52]. More importantly, though the creation of WHO’s new

Health Emergencies Programme represents a critical in- ternal governance “drift”, structural reforms that would represent the needed governance “shift” to modernize WHO continue to lack the necessary political will and fi- nancial support for what would likely be a much more expensive reform process [14]. For example, restructur- ing of WHO’s current HQ/regional office/country office organizational structure has not been seriously consid- ered, with the focus instead on bolstering staffing and support for WHO country offices and relying on the newly formed Health Emergencies Programme to en- hance coordination [14, 38, 53]. The importance of re- structuring WHO-led coordination (between WHO HQ, regional and country offices, and other support chan- nels) was made evident by the lack of sufficient commu- nication and coordination between WHO HQ and its largely autonomous regional office AFRO, a factor iden- tified as contributing to the spread of EVD [13, 53]. Additionally, a needed increase and stabilization of

WHO’s core budget (an 8% increase in voluntary contri- butions was approved at the 68th WHA but a 5% in- crease in member state assessments for the core budget

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was not; and a recent October 2016 WHO financing dia- logue including a proposal by DG Chan to raise assessed contributions 10% received mixed reactions/support) has not been carried out, despite universal recommendation from all the panels on the need for more sustainable fi- nancing. Further, though the US$160 million increase in WHO’s budget to fund the Health Emergencies Pro- gamme (which remains only 56% funded as of Oct 2016) is a needed investment, it falls far behind the CGHRF recommended annual investment of $4.5 billion to strengthen global infectious disease capacity []. Finally, though the WHO adopted a Framework for Engagement with Non-State Actors (FENSA) at the 69th WHA follow- ing 2 years of intergovernmental negotiations, the struc- ture of the framework is limited to operational procedures and engagement management, and has also been criti- cized by certain stakeholders [14, 54, 55]. As such, it will likely fall short in establishing robust partnerships and creating a much needed space for formal interac- tions between WHO and critical non-state actors clearly needed during health emergencies.

Greater Leadership by the UN in Global Health? Growing recognition of the importance of global health and the unremitting threat of an emerging infectious disease outbreak may make it untenable to simply wait and hope for a sufficiently reformed WHO. Instead, the lasting legacy of the EVD outbreak may be its foresha- dowing of a governance “shift” in formal sharing of the complex responsibilities of global public health and health security to other international structures, most notably various organs of the United Nations [36]. In September 2014, the UN authorized the first-ever UN emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER), and thus became the central actor charged with mobilizing and coordinating resources across UN agencies, multiple states, and other partners working to stop EVD. UNMEER was estab- lished as a temporary measure to provide immediate financial, human resource, and logistic support for af- fected countries with the primary objectives of stopping the outbreak, treating the infected, ensuring access to es- sential services, creating stability, and preventing further escalation [56]. However, UNMEER’s participation has not been without criticism. In fact, reports by panels/ commissions have noted that while UNMEER brought high-level political and financial support, coordination of the crisis became more difficult during its tenure in affected countries [38, 39]. Nevertheless, UNMEER’s cre- ation brings a new dimension to global health govern- ance as it is the first apparatus constructed to provide a singular UN system-wide approach in order to establish unity in combating a public health emergency. In addition to UNMEER, David Nabarro (who acted as

Chair of the WHO Advisory Group and who is also a current candidate for the new WHO DG) was appointed as the UN Secretary-General's Special Envoy on Ebola in August 2014, for the purpose of providing strategic and policy direction to improve the international response to EVD. UNMEER’s creation, though not viewed as entirely

successful, may serve as a precursor for what future glo- bal health governance structures could look like in the absence of an adequately strengthened and empowered WHO. Hints of this potential governance “shift” mani- fested in different panel recommendations, with all panels calling for some form of increased involvement by the larger UN system. Specifically, the Interim Panel called for the appointment of a Special Representative of the Secretary-General or a UN Special Envoy for high- level global health threats, but stopped short of recom- mending the establishment of a full UN mission [57]. The Harvard-LSHTM report concluded that an inde- pendent UN Accountability Commission was needed to assess worldwide responses to outbreaks and also rec- ommended the creation of a Global Health Committee as part of the UN Security Council [39]. The CGHRF called for better communication and collaboration mechanisms between WHO and the UN (including an escalation process to transfer control of emergencies from WHO to the UN Secretary-General,) and also specified that the UN Secretary-General should lead in developing strategies for sustaining health system capaci- ties in fragile/failed states, though it did not support the creation of a new UN entity [41]. The UN’s own Kikwete Panel specifically recommended the creation of a High- level Council on Global Public Health Crises housed within the General Assembly made up of 45–50 political representatives of member states in order to ensure political accountability and reform implementation [42]. Germany's Chancellor Angela Merkel’s keynote speech at 68th WHA was even more direct, stating that WHO cannot tackle Ebola or global health on its own, and that its cooperation with the broader UN system and World Bank is a critical component of any reform moving for- ward [58, 59].

A UN High-Panel on Global Health: 21st Century Global Health Governance? Though calls for greater involvement by the UN in glo- bal health have accelerated following the EVD outbreak, recommendations for a permanent UN global health structure are not new. As early as 2012, this author spe- cifically advocated for the formation of a UN Global Health Panel chaired by WHO, which could alternatively be housed within the UN Economic and Social Council (ECOSOC) - a central mechanism of the UN system that has been active in global health issues (including

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developing the UN Sustainable Development Goals) and is the principal UN organ coordinating work across its 14 specialized agencies [45]. ECOSOC represents an op- timal space to establish cooperation, coordination, and policy coherence across the entire UN system, its tech- nical agencies, and its respective stakeholder networks on key global health challenges, including health emer- gencies (see Fig. 1 for visualization of governance rec- ommendations by the panels and the UN Global Health Panel recommendation) [45]. An ECOSOC UN Global Health Panel would meet

many of the needs identified in post-EVD governance re- form discussions, including acting as a permanent central body to coordinate global health efforts across the entire UN system (including alignment with the SDGs), allowing engagement with a broader array of stakeholders and cre- ating a "safe space" for these interactions through its part- nership initiatives and forums, and could be designed in a way that would afford it greater political visibility as well as increased accountability by having it report directly to the UN General Assembly [37, 45, 60–62]. Similarly, the creation of a Global Health Committee contained

within the UN Security Council - as recommended by the Harvard-LSHTM panel - could also elevate health emer- gencies to the highest levels of political attention and raise awareness among key decisionmakers. However, the highly political nature of the Security Council could also result in public health priorities being stymied by larger and more influential political, security, and core foreign policy dynamics, as has been the case in other health dip- lomacy outcomes [63–65]. Further, the High-level Council proposed by the Kikwete Panel would not implicitly in- clude important multistakeholder representation from international public health agencies, non-state actors, NGOs, civil society, and other health actors, instead rely- ing upon the exclusive participation of member state polit- ical representatives. More fundamentally, critical in assessing whether any

UN global health apparatus will work as a central pillar in the future architecture of global health governance is defining the appropriate roles and responsibilities of WHO with respect to other UN institutions that are already actively participating in global health [60]. This is necessary in order to avoid duplication and ensure effective

Fig. 1 Visualization of Global Health Governance Reform Structures. Attached as separate file

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coordination, a challenge highlighted by the temporary and emergency nature of the UNMEER governance interven- tion during EVD. This would require focusing a proposed UN global health panel’s structure on galvanizing high-level political and financial attention to a health emergency/out- break, while also creating a permanent policy and govern- ance environment conducive to multistakeholder partnership building, coordination, and mobilization of resources that is beyond the scope of WHO’s current operational mandates and capacity. However, this structure would also need to leverage

the unique strengths of WHO, specifically allowing the embattled agency to focus on its indispensable role as the world’s chief technical health agency by imbuing it as the Chair of the proposed structure and having the newly established WHO Health Emergencies Programme take a leading role when addressing issues related to health emergencies and outbreask with panademic poten- tial [45]. Though some may view a UN-based structure as usurping WHO’s credibility and leading to duplication, by positioning WHO as the chair of a UN Global Health Panel, such a structure could serve the dual role of rees- tablishing WHO’s relevance and strengthening its re- sponse capabilities [66–68]. This would be accomplished by enabling WHO with high-level political representation and access to all the resources at the UN system’s disposal. Through this structure, WHO could then establish

clear and delineated roles for other actors when prepar- ing for and responding to health emergencies. It could then act as both the primary coordination mechanism and provide technical support to other UN institutions, such as the World Bank, UN Development Programme, UNICEF, UNAIDS, UN Environmental Programme, UN Population Fund, UN Office of Drugs and Crime, Food and Agriculture Organization, many of whom were active participants in the fight against EVD [45]. The de- sign of the structure should also leverage existing inter- agency structures already established between WHO, the UN and other health partners (including the Global Health Cluster and Inter-Agency Standing Committee that both focus on humanitarian and health issues.) [13]. In this sense, a UN global health panel apparatus could act as a hybrid multistakeholder global health body bringing together the respective organizational and part- nership networks available between the UN system and WHO. This would enable more robust engagement with key civil society actors, NGOs, foundations, civil-military cooperation, and private sector actors that will be critical in the prevention, detection, and response to future health emergencies and potential pandemics. Finally, by placing global health, health emergencies,

and infectious disease governance at the top of the UN hierarchy, the opportunity to establish greater policy

coherence across the entire landscape of global govern- ance mandates and instruments could be better realized by a UN Global Health Panel. This includes ensuring that all member states, UN agencies, and non-state part- ners are aligned under SDG goals 3.b (supporting R&D for infectious diseases), 3.c (ensuring a sustainable health workforce in developing countries) and 3.d (strengthen- ing capacity for risk reduction and management of glo- bal health risks), all factors critical in preventing and responding to infectious disease outbreaks. This in turn could translate to better funding, strengthening, and im- plementation of the IHR and the WHO R&D Blueprint, while also supporting wider adoption of the WHO Global Code of Practice on the International Recruitment of Health Personnel [69, 70]. Additionally, other global health governance mechanisms can also be championed at highest levels of political engagement, including pro- posed instruments such as the biomedical R&D treaty and the Framework Convention for Global Health, which could bolster the normative powers of WHO [29, 71, 72]. This could establish a strengthened global health govern- ance system, a step that is needed to ensure that global health and infectious disease outbreaks are given their rightful priority in the echelons of foreign policy and inter- national affairs.

Summary Only time will tell if the legacy of EVD will include a WHO that has the full support of the international com- munity and is capable of leading human society in this brave new era of globalization and health. Despite current uncertainty, the time is ripe for a radical “shift” in global health governance by recognizing that complex global health challenges can no longer be borne by WHO alone. Instead, global health demands a UN systems wide ap- proach lead by a permanent UN Global Health apparatus combined with WHO reforms that are fair to the agency’s current funding and capacity limitations while also lever- aging its core strengths as the world’s preeminent inter- national health body. The urgency for these reforms comes at a time when global health is increasingly becom- ing a foci for the security, economic, social, political and health interests of all nation states, necessitating greater shared leadership. In this sense, the impact of the EVD outbreak is likely to go far beyond the immense human suffering and lives lost during this tragedy, extending to the very foundation of how we approach governance for global health in the 21st century.

Abbreviations AFRO: World Health Organization Regional Office for Africa; CGHRF: Commission on a Global Health Risk Framework for the Future; DG: Director General; ECOSOC: United Nations Economic and Social Council; EVD: Ebola virus disease outbreak; FAO: Food and Agriculture Organization of the United Nations; FENSA: WHO Framework for Engagement with Non-State Actors; GOARN: WHO Global Outbreak Alert and Response Network; Harvard-

Mackey BMC Infectious Diseases (2016) 16:699 Page 10 of 12

LSHTM panel: External independent panel jointly convened by the Harvard Global Health Institute-London School of Hygiene & Tropical Medicine; In- terim Panel: WHO Interim Assessment panel established by the WHO Executive Board; IHR: International Health Regulations; IMF: International Monetary Fund; Kikwete Panel: High-Level Panel on Global Response to Health Crises appointed by UN-Secretary General Ban Ki-moon; PHEIC: Public Health Emergency of International Concern; UN: United Nations; UNAIDS: Joint United Nations Programme on HIV/AIDS; UNDP: United Nations Development Programme; UNEP: United Nations Environment Programme; UNFPA: United Nations Population Fund; UNICEF: United Nations Children’s Emergency Fund; UNMEER: United Nations Mission for Ebola Emergency Response; UNODC: United Nations Office on Drugs and Crime; WHA: World Health Assembly; WHO: World Health Organization; WHO Advisory Group: High-level Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies; WHO HQ: World Health Organization Head Quarters (Geneva, Switzerland)

Acknowledgments The author would like to thank Matthew Brown, Assistant Professor at the Division of Global Health - Uniformed Services University, for his helpful comments and insight in preparation of this manuscript.

Funding Author reports no funding associated with this manuscript.

Availability of data and materials All data and materials used in this study are included in the references.

Authors’ contributions In respect to author contributions, TM solely conceived, wrote, edited, and finalized the manuscript.

Authors’ information TM is an Assistant Professor of Anesthesiology and Global Public Health at University of California, San Diego School of Medicine, the Associate Director for the UC San Diego MAS Program in Health Policy & Law, and the Director of the Global Health Policy Institute. He has also completed an Executive Course in Global Health Diplomacy at the Graduate Institute, Geneva, worked as a consultant for the World Health Organization, and acted as an expert speaker the U.S. Department of State. His work focuses on global health policy and governance.

Competing interest Author reports no conflicts of interest or funding associated with this manuscript.

Consent for publication Not applicable.

Ethics approval and consent to participate Not applicable.

Author details 1Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA. 2Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA, USA. 3Global Health Policy Institute, 6256 Greenwich Drive, Mail Code: 0172X, San Diego, CA 92122, USA.

Received: 8 June 2016 Accepted: 10 November 2016

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