Public health emergencies: preparedness and response: report of the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme

SEVENTY-SECOND WORLD HEALTH ASSEMBLY A72/6 Provisional agenda item 11.2 7 May 2019 Public health emergencies: preparedness and response Report of the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme The Director-General has the honour to transmit to the Seventy-second World Health Assembly the report submitted by the Chair of the Independent Oversight and Advisory Committee (see Annex). A72/6 2 ANNEX REPORT OF THE INDEPENDENT OVERSIGHT AND ADVISORY COMMITTEE FOR THE WHO HEALTH EMERGENCIES PROGRAMME BACKGROUND 1. The establishment of the WHO Health Emergencies (WHE) Programme was an outcome of WHO’s reform of its work on outbreaks and emergencies, pursuant to resolution EBSS3.R1,1 adopted by the Executive Board at its 2015 Special Session on the Ebola emergency, and decision WHA69(9)2 adopted by the Sixty-ninth World Health Assembly in 2016. Concomitantly the Independent Oversight and Advisory Committee for the WHE Programme (IOAC)3 was created to provide independent scrutiny of WHO’s implementation of the reform, and its management of health emergencies. The initial term of office of the Committee members was two years, beginning in May 2016. 2. Since its inception, the IOAC has been monitoring the performance of the WHE Programme and providing advice to the Director-General in accordance with its mandate. The IOAC completed its first term of office in May 2018 and the WHO Director-General made the decision to continue the Committee’s function for a further two years. The IOAC membership for 2018–2020 was announced during the Seventy-first World Health Assembly.4 The IOAC’s findings and observations thus far have been transmitted to the WHO governing bodies through five reports.5 3. This is the sixth IOAC report and is based on the activities of the new IOAC membership between May 2018 and March 2019. During this time, the IOAC held four regular teleconferences and two in-person meetings, undertook one country visit to Uganda, and analysed and reviewed data. Its review – informed by scrutiny of the data in the IOAC monitoring framework, information provided to the IOAC as well as interviews, field visits and presentations – was focused on issues grouped into three categories identified in the monitoring framework:6 key elements of the WHE Programme, WHO’s transformation agenda and WHE programmatic areas. 4. In response to a request from the Director-General at the 144th session of the Executive Board (EB144),7 the IOAC undertook a review of corporate cultural issues that could impact the performance of the WHE Programme. During February and March 2019, the IOAC reviewed data, policies and reports, and carried out interviews to assess the WHE Programme workforce with regard to: diversity; 1 Resolution EBSS3.R1 (see http://apps.who.int/gb/ebwha/pdf_files/EBSS3-REC1/EBSS3_REC1-en.pdf, accessed 15 April 2019). 2 Decision WHA69(9) (see http://apps.who.int/gb/ebwha/pdf_files/WHA69-REC1/A69_2016_REC1-en.pdf, accessed 15 April 2019). 3 IOAC (https://www.who.int/about/who_reform/emergency-capacities/oversight-committee/en/, accessed 15 April 2019). 4 See the summary records of the Seventy-first World Health Assembly, Committee A, fourth meeting, section 3. 5 IOAC previous reports: documents EB140/8, A70/8, EB142/8, A71/5 and EB144/8. 6 IOAC monitoring framework for WHO/WHE – revised version (https://www.who.int/about/who_reform/emergency-capacities/oversight-committee/ioac-monitoring-framework- sep2018.pdf?ua=1, accessed 15 April 2019). 7 See the summary records of the Executive Board at its 144th session, eighth meeting. Annex A72/6 3 the human resources (HR) policy for recruitment, career development and performance management; and the WHO grievance mechanism. The present report includes some of the findings and recommendations that are most pertinent to the WHE Programme. 5. The IOAC has also been commissioned to contribute to a report of the Global Preparedness Monitoring Board, which will cover a comparison between the response to the 2018–2019 outbreaks of Ebola virus disease (EVD) in the Democratic Republic of the Congo, coordinated by WHO, and the response to the EVD outbreak in West Africa in 2014. The ongoing research includes a mission to the Democratic Republic of the Congo to assess the Ebola response on the ground in the current outbreak areas, and progress in implementing the global recommendations that emerged from reviews of the West African 2014 EVD outbreak. The initial phase of desk research and preliminary interviews with stakeholders has been completed, the outcomes of which are included in the present report. PROGRESS, CHALLENGES AND OPPORTUNITIES 6. The IOAC commends the Director-General and the Regional Directors for their strong commitment and strategic vision in reaffirming WHO’s work in emergencies as one of the Organization’s top three priorities. The IOAC welcomes the Director-General’s announcement of the new structure of WHO’s Emergency Preparedness and Response pillar, which provides greater senior management capacity and a stronger preparedness component that should interface with the emergency response. This reorganization will afford an opportunity to review the current WHE Programme structure, which was designed in 2016, to optimize the workforce, and to define clear roles and responsibilities, based on actual functions and the challenges and opportunities that WHO is facing. The IOAC believes that such changes should enable WHO to better perform in emergencies and strengthen national preparedness. 7. The IOAC welcomes the progress made in the transformation agenda in line with the Thirteenth General Programme of Work, 2019–2023.1 While recognizing the intent to harmonize cross-cutting functions and consolidate structures across the Organization, the IOAC cautions that such centralization could dilute the WHE Programme’s distinctive functions and agile business processes, which are prerequisites to operating effectively in emergency contexts. 8. The current EVD outbreak in the Democratic Republic of the Congo, in the North Kivu and Ituri provinces, which has been ongoing since late July 2018, is the second largest on record after the 2014–2015 outbreak in West Africa. The outbreak in the North Kivu and Ituri provinces closely followed the EVD outbreak in Equateur province in the Democratic Republic of the Congo that began in May 2018 and ended in July 2018. The dedication and bravery of the front-line responders is highly laudable and should be commended. The response has in many respects been a proof-of-concept test for the WHE Programme, but has also highlighted the challenges of performing public health functions in a complex political context. The declining trend of the current EVD outbreak noted by the IOAC in its report to the Executive Board at its144th session in January 2019,2 has been reversed and transmission is increasing at the time of writing this report. The Ebola virus has since spread southwards of the provinces of North Kivu and Ituri amid protracted armed conflict. These provinces are affected by a long-lasting humanitarian crisis and the response is complicated by profound insecurity and deep community mistrust. 1 Thirteenth General Programme of Work, 2019–2023 – resolution WHA71.1 (http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_R1-en.pdf, accessed 15 April 2019). 2 Document EB144/8 (http://apps.who.int/gb/ebwha/pdf_files/EB144/B144_8-en.pdf, accessed 19 April 2019). A72/6 Annex 4 WHO leadership and health emergencies management 9. The IOAC affirms WHO’s efforts to reposition itself as both a technical and an operational organization leading emergency responses to global health crises on the ground. As at March 2019, WHO is responding to 160 ongoing events and a total of 33 graded crises, nine of which are graded level 3, including the current EVD outbreak in the Democratic Republic of the Congo, and Cyclone Idai and flooding in Mozambique, Malawi and Zimbabwe.1 The IOAC perceives that partners and donors have increased confidence in WHO’s leadership in health emergencies, but the EVD outbreak in particular has revealed areas requiring further progress. WHO faces increasing challenges of responding to acute outbreaks on a large scale while also dealing with protracted crises. 10. Following Cyclone Idai, which displaced 130 000 people in Mozambique and left 1.85 million people in need of humanitarian assistance, the IASC2 Humanitarian System-Wide Scale-Up protocols were activated, triggering a grade 3 response under the WHO Emergency Response Framework on 22 March 2019. In the wake of the cyclone, more than 1741 suspected cases of cholera were reported in Sofala province. The IOAC recognizes that WHO immediately set up an incident management team, rapidly released US$ 4.3 million from the Contingency Fund for Emergencies (CFE) and deployed more than 50 staff to Mozambique within 10 days. More than 18 international emergency medical teams (EMTs) have also been deployed to provide primary and clinical health care to affected communities. WHO is also supporting Malawi and Zimbabwe in procuring medical supplies, including oral cholera vaccine, Interagency Emergency Health Kits and disease-specific kits for cholera and malaria, and is working with and coordinating partners on surveillance for infectious diseases. 11. The IOAC is pleased to see that the Emergency Response Framework (ERF)3 has been consistently adhered to and that an incident management system (IMS) has been fully institutionalized for graded crises. In the course of 2018, the IMS was activated for 21 new graded events, in line with the ERF procedures. The IOAC observed increased coherence among IMS staff and improved decision-making processes and coordination across the three levels of the Organization through the formalized IMS structure. However, inconsistent application of delegation of authority (DOA) was noted across the different offices. The IOAC recommends that reporting lines and performance management of staff deployed as surge capacity should be clarified and adapted to specific emergency contexts to ensure operational effectiveness. 12. As at 31 March 2019, 1089 cases, including 1023 confirmed and 66 probable cases, had been reported in the current EVD outbreak in the Democratic Republic of the Congo, with an overall case fatality ratio (CFR) of 62%.4 Attacks from armed groups on Ebola treatment facilities and sporadic violence disrupt daily operations and put staff security at high risk. Despite the challenges, WHO remains in the field co-leading the Ebola response along with the Ministry of Health of the Democratic Republic of the Congo. As at 31 March 2019, 7210 contacts of EVD cases were under surveillance in 16 health zones in the Democratic Republic of the Congo and about 84% of them had been followed up. Despite WHO’s extraordinary efforts to contain the outbreak, the transmission trends have moved in the wrong direction in recent weeks. Given how strained WHO already is by the challenge of managing this outbreak, on top of numerous other grade 3 emergencies, and the emerging shortfalls in financing, the 1 Emergencies (https://www.who.int/emergencies/crises/en/, accessed 15 April 2019). 2 Inter-Agency Standing Committee. 3 Emergency response framework, 2nd edition (http://www.who.int/hac/about/erf/en/, accessed 15 April 2019). 4 External situation report 35 (https://apps.who.int/iris/bitstream/handle/10665/311641/SITREP _EVD_DRC_20190331-eng.pdf?ua=1, accessed 15 April 2019). Annex A72/6 5 IOAC is concerned about the efficacy and sustainability of the existing response configuration. The IOAC recommends that WHO further leverage partners on the ground and develop a policy for surge capacity to authorize the release of technical expertise within the Organization at all levels. 13. The IOAC commends WHO’s leadership in implementing experimental Ebola vaccines and investigational therapeutics under the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI) protocol. The Ebola vaccine and the ring vaccination strategy have proven highly effective.1 Current estimates indicate that it has an efficacy of 97.5% against EVD (comparable to previously reported data) and no deaths have been reported among vaccinees who developed EVD 10 or more days after vaccination. Only two out of 68 279 vaccinated contacts of contacts developed EVD, illustrating the ability of the vaccine and of ring vaccination to prevent tertiary infections. The IOAC observes that, despite the challenges of community engagement, there is good acceptance of vaccination and treatment at the Ebola treatment centres. As at March 2019, over 93 000 contacts and contacts of contacts have been vaccinated, including 42 000 health care workers, and about 400 patients have been treated under the MEURI protocol. 14. Community acceptance and engagement is one of the most critical success factors in an outbreak response. The IOAC noted that Ebola response activities are being constantly hampered by violence organized by rebel groups and sporadic attacks by communities. Disproportionate attention given to Ebola might have deepened mistrust among communities that have been suffering as a result of a humanitarian crisis for two decades. The IOAC acknowledges the difficulty of building trust during this crisis and the need to counterbalance Ebola response efforts with broader development, including education, water safety, and health care services for other diseases. The IOAC encourages WHO to work with partners to improve social cohesion and community engagement. 15. The IOAC commends the Government of the Democratic Republic of the Congo for its leadership and strong ownership of the Ebola response, and recognizes the excellent work and crucial role of the Institut National de Recherche Biomédicale (INRB).2 The IOAC emphasizes that the quality assurance of laboratory testing and timely analysis of genetic sequencing data are critical to fully characterize the evolution of the EVD outbreak in order to inform diagnostic, vaccine and treatment approaches and recommends closer collaboration between INRB and WHO. Human resources 16. Between the declaration of the current EVD outbreak in August 2018 and March 2019, over 1200 staff have been deployed through WHO to North Kivu province, Democratic Republic of the Congo, to support the response. The IOAC observed that, immediately after the end of the outbreak in Equateur province in July 2018, most of the WHE Programme staff who had been deployed to Equateur were redirected to fill IMS leadership positions in North Kivu. The IOAC is concerned about staff exhaustion and shortage of staff who have the necessary skills to manage emergencies. Noting that about 60% of deployment to North Kivu has been managed through external recruitment, the IOAC recommends that WHO increase the supply of a diverse pool of competent staff to lead 1 Preliminary results on the efficacy of rVSV-ZEBOV-GP Ebola vaccine using the ring vaccination strategy in the control of an Ebola outbreak in the Democratic Republic of the Congo: an example of integration of research into epidemic response (https://www.who.int/csr/resources/publications/ebola/ebola-ring-vaccination-results-12-april-2019.pdf, accessed 23 April 2019). 2 INRB (http://inrb.net/, accessed 15 April 2019). A72/6 Annex 6 emergencies, further develop incident managers’ rosters and create deputy incident manager posts that are preferably filled by under-represented suitably skilled groups. 17. Although the IOAC acknowledges the substantial surge in capacity that WHO has managed for this outbreak, it cautions against the heavy reliance on deployment from headquarters (HQ) and regional offices (ROs) and reiterates the need for strengthening country office staffing and capacity-building. The IOAC recommends that WHO give high priority to its country offices in fragile States and accelerate the implementation of the WHE country business model that includes plans to increase HR capacity and staff trained in emergency response at the country level. In its previous report,1 the IOAC noted that only 53% of planned positions at the country level were filled as at October 2018; no progress has been made since then. The IOAC reiterates that recruitment in priority country offices that are bolstering emergency surge capacity should not be held back by the transformation agenda. 18. The IOAC welcomes the Organization’s efforts to improve diversity and recommends using the WHE Programme as a pilot for the Organization in this regard. For example, functional networks could facilitate the rotation and lateral transfer of staff within the WHE Programme to improve diversity at HQ and ROs. The IOAC emphasizes that special consideration should be given to staff working in emergencies at hardship duty stations, commensurate with the stress and pace of WHO’s emergency field operations. The experience of the WHE Programme and the advantage of having a diverse workforce for emergency response should be leveraged across other programmes. 19. The IOAC recommends that WHO should develop a system of performance management that includes 360-degree feedback and that WHO core competencies2 should be reinforced by introducing the element of assessing how outcomes have been achieved. Staff should be provided with training on giving and receiving feedback in an effective and constructive manner, which is critical when working under the pressure of responding to public health emergencies and humanitarian crises. The IOAC also recommends that WHO establish a promotion system that rewards high-performing staff and motivates others. 20. The WHO all-staff culture survey was conducted in November 2017 as part of the transformation agenda: the IOAC notes that the outcomes have provided a baseline from which to track further improvements, in particular management practices and leadership. The IOAC recommends that there should be an annual or biennial staff culture survey and supports the Director-General’s plan to undertake a similar survey on a regular basis and pulse surveys at regular intervals. It is particularly important for the WHE Programme to monitor progress against the baselines provided in the survey. The IOAC notes with concern that the baseline survey indicated higher levels of staff dissatisfaction in the WHE Programme than in the Organization at large; the subsequent pulse surveys will be important to gauge improvements in the effectiveness and openness of management. The IOAC recommends that WHE Programme leadership develop an action plan for implementing improvements against the outcomes of the survey, and that performance on this plan be reported within the IOAC reporting framework. 21. Whilst recognizing WHO’s transformation effort, the IOAC notes that the WHE Programme has unique communications, resource mobilization and HR requirements, given the speed and subject expertise required for emergency response. The IOAC also notes that specific requirements for risk 1 Document EB144/8 (http://apps.who.int/gb/ebwha/pdf_files/EB144/B144_8-en.pdf, accessed 19 April 2019). 2 WHO global competency model (https://www.who.int/employment/WHO_competencies_EN.pdf?ua=1, accessed 23 April 2019). Annex A72/6 7 communication, as opposed to corporate communication, should be taken into account. The IOAC recommends that transitional steps be taken to ensure that the centralized corporate structure does not dilute the particular and immediate needs of emergency operations and risk mitigation. The IOAC will track these critical enabling functions, such as communications, resource mobilization and HR, to ensure that their effectiveness is maintained and improved. 22. The IOAC also emphasizes that emergency expertise and the relations that WHE Programme staff have with donors should be maintained and further enhanced. Staff security, protection and welfare 23. The IOAC recognizes that WHO conceives of security as an institutional function and welcomes WHO’s corporate investment in security and its implementation in the WHE Programme response in the Democratic Republic of the Congo. The successful provision of security services for the Ebola response could be a model for centralization of business operations as envisioned by the transformation agenda. The IOAC emphasizes that cost estimates for emergency responses should include budgets for staff security, protection and well-being. WHO is advised to accelerate the ongoing recruitment process for security staff at HQ and development of a corporate security strategy in alignment with the United Nations (UN) Security Management System. 24. The IOAC cautions that security strategies affect community trust and must not undermine community engagement. The IOAC recognizes that WHO has amended its security strategy to reflect the different Ebola epicentres in the Democratic Republic of the Congo in order to maintain operational security and sustain community trust in a highly politicized and volatile environment. The IOAC notes that the affected communities are diverse in terms of ethnic, linguistic, political and socioeconomic characteristics. Building their trust will require strategic use of the anthropological and political analysis that is available. Given that the EVD outbreak has arisen in complex and insecure settings affected by long-lasting conflicts, strategies used in the polio response or a humanitarian security model could be useful. 25. WHO has established unprecedented collaboration with the UN Stabilization Mission in the Democratic Republic of the Congo (MONUSCO) to ensure the safety of staff who are responding to the EVD outbreak in the field. Additionally, the Director-General’s briefing to the UN Security Council culminated in the unanimous adoption of resolution 24391 on 30 October 2018, urging all parties to ensure Ebola responders’ safety in the Democratic Republic of the Congo. The IOAC acknowledges WHO’s strong commitment to duty of care and staff protection measures in the field including security evacuation, general medical evacuation, Ebola medical evacuation and psychological support. 26. Although protecting staff against security threats in field operations is critical, it is also essential to ensure safety and security within the Organization as a whole. WHO has a number of grievance and redress mechanisms, but these do not seem to be perceived by staff as reliable or effective. In 2018, a total of 336 cases were dealt with by the Office of the Ombudsman and Mediation Services (OMB), 148 reports of concern were received by the Office of Internal Oversight Services (IOS) and 73 cases were reported through the Integrity Hotline. The proportion of cases directly linked to WHE Programme activities was 16% for the OMB, 10% for IOS and 0.05% for the hotline. The overall low level of use of grievance mechanisms, both in WHO as a whole and in the WHE Programme, suggests to the IOAC both a lack of awareness and a lack of staff trust in the mechanisms. The IOAC recommends that WHO clarify and simplify the various elements of the grievance and redress system to build 1 UN Security Council resolution 2439 (http://unscr.com/en/resolutions/doc/2439, accessed 15 April 2019). A72/6 Annex 8 greater staff trust in the mechanisms, and to make them more responsive. Staff protection and well-being is important for emergency management, particularly in remote field contexts. The WHE Programme senior management should ensure that effective staff welfare and protection measures are in place both in the field and at all levels of the Organization, and make them accessible and responsive. Partnership and coordination 27. Whilst significant progress has been made in WHO’s response to the current EVD outbreak and research and preparedness on the ground, the IOAC is concerned that the WHE Programme has struggled to cultivate reliable external partnerships for outbreak response – due in part to staff turnover among external partners and the resulting loss of experience gained during the 2014–2015 EVD outbreak. The IOAC recommends that further efforts be made to proactively reach out to these partners, including humanitarian actors, and to establish long-term partnerships with key nongovernmental organizations (NGOs) for managing outbreaks. Deeper engagement with key NGOs with regard to alignment of technical standards, financial arrangements, staff training, and development of joint protocols and standard operating procedures (SOPs) under a formalized commitment on a long-term basis will significantly improve collective capacity in terms of preparedness and response to large-scale health emergencies. 28. The IOAC was briefed that WHO decided not to activate the IASC Humanitarian System-Wide Scale-Up Activation Protocol for the Control of Infectious Disease Events for the two EVD outbreaks in the Democratic Republic of the Congo in 2018, but that the Organization is playing a leadership role in coordinating the Ebola response and actively engaging with the IASC. Whilst the streamlining and coherence provided by the emergency operation centre (EOC)-centric incident management system approach to outbreak response brings substantial benefits in terms of planning and coordination, the interface with existing health cluster and sector partners continues to present challenges. The IOAC observes that the humanitarian coordination mechanisms in the Democratic Republic of the Congo, including the health coordination cluster, have been underutilized in the Ebola response and recommends more proactive engagement of the existing capacity of humanitarian partners. Improved alignment between health cluster coordination and the activation of government-led EOCs is advised. The IOAC recommends that the health cluster coordinators work closely with incident managers to enable closer engagement and effective coordination. 29. The IOAC notes that no progress has been made in the staffing of health cluster positions since the previous IOAC report to the Health Assembly.1 Nineteen out of 27 country health clusters2 have dedicated health cluster coordinators and 12 Information Management Officers (IMOs). Further efforts are required to accelerate recruitment of candidates who have skill sets that match specific country needs. The IOAC recommends improving the quality of the HCCs roster through adequate assessment of candidates, training on field-level health cluster coordination prior to deployment, and providing adequate support on deployment to ensure satisfactory information management and coordination. 30. The IOAC was briefed that more than 130 countries are aware of the WHO Emergency Medical Teams Initiative3 and that WHO has supported 35 countries in strengthening active EMT processes. 1 Document A71/5 (http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_5-en.pdf, accessed 23 April 2019). 2 Health Cluster (https://www.who.int/health-cluster/en/, accessed 15 April 2019). 3 Emergency Medical Teams (https://extranet.who.int/emt/, accessed 15 April 2019). Annex A72/6 9 Using the nationally led coordination approach, several countries such as Indonesia (after the Sulawesi earthquake in 2018) and the Philippines (after Typhoon Mangkhut in 2018) have been able to coordinate medical team responses to emergencies. Medical teams continue to run treatment centres across North Kivu in the Ebola response. Most recently, in response to the emergency caused by Cyclone Idai, the Government of Mozambique required all international EMTs to adhere to the EMT guiding principles and minimum standards, and was directly supported by WHO in coordinating the response of more than 14 international EMTs. The IOAC acknowledges WHO’s efforts to set global standards for EMTs and recommends that WHO continue engaging and working collaboratively with national medical response teams and disseminating best practice at the field level. 31. The IOAC reiterates the importance of continued focus on building the depth and operational capacity of the Global Outbreak Alert and Response Network (GOARN).1 The IOAC was briefed that about 160 experts from 41 GOARN partner institutions were deployed to 13 countries for emergency operations during 2017–2018. A total of 118 experts were deployed from 35 institutions to 17 different health emergencies during 2016–2017. From the beginning of the EVD outbreak in August 2018 to March 2019, 22 experts have been deployed on an individual basis to support the Ebola response in the field. The IOAC recommends establishing institutional arrangements for GOARN deployment to improve accountability and ensure the safety of deployed experts. WHE Programme finance 32. As at March 2019, about 84% of the WHE Programme core budget requirement of US$ 526 million has been funded or pledged for the biennium 2018–2019. The IOAC notes that the WHO core flexible funding has been reduced by US$ 39 million and is concerned that this will negatively affect the implementation of the WHE Country Business Model. The IOAC emphasizes that corporate core flexible funding is fundamental to the WHE Programme as it provides sustainability in financing. 33. The total amount requested to fund outbreak and crisis response is US$ 1.2 billion for the biennium 2018–2019; more than 94% of this has already been received or has been pledged. These figures indicate that WHO has steadily improved its ability to fundraise and has gained the confidence of humanitarian donors through its strong field presence and improved performance in emergency operations. 34. Out of a target capitalization of US$ 100 million for the CFE, US$ 70.7 million has been funded as at March 2019. The IOAC notes that more countries now recognize the CFE’s critical value in WHO’s early response to health emergencies. While 16 countries made contributions to the CFE between January 2018 and March 2019, replenishment of the CFE is still challenging. The IOAC observes that the objective of the CFE was to fill in gaps in cash flow for the Ebola crisis; it appears that the CFE is not being used for its intended purpose. 35. The IOAC recognizes that the WHE Programme has been able to mobilize substantial resources, and cautions that, while it appreciates the need to avoid duplication, expertise in emergency-specific resource mobilization and donor relations should not be diminished through centralization in the context of the transformation agenda. The centralized Resource Mobilization function must work in close coordination with the leadership and technical experts within the WHE Programme to maintain the same level of success in donor relations. 1 Global Outbreak Alert and Response Network (https://extranet.who.int/goarn/, accessed 15 April 2019). A72/6 Annex 10 36. The EVD outbreak demonstrated WHO’s ability to raise funds for acute events, but mid-term and long-term financing face challenges as the crisis extends. In contrast to the extremely positive donor response to the first response plan1 for the EVD outbreak in the Democratic Republic of the Congo, the third strategic response plan for the province of North Kivu suffered from a US$ 72 million funding gap out of a total funding requirement of US$ 148 million at the most challenging phase of the Ebola response. The IOAC was briefed that WHO is covering unforeseen operating costs, obligations to implementing partners and payments to national workers to ensure there is no disruption to the response. These costs are estimated to amount to US$ 39 million and are additional to WHO’s budget requirements of US$ 57 million. As at March 2019, the WHO funding gap against its requirement in the third strategic response plan is about 56%. Given that only a few donors have stepped up with significant funding, the IOAC urges donors to contribute in order to bring the current EVD outbreak in the Democratic Republic of the Congo under control and to contain the spread to surrounding countries. 37. The World Bank Pandemic Emergency Financing Facility (PEF)2 have approved up to US$ 32 million in grants and credits to support the Democratic Republic of the Congo’s Ebola response. The PEF offers great leverage for health emergency management and WHO is encouraged to work closely with the World Bank. The IOAC also notes, that predominant World Bank funding of a crisis response creates different dynamics for the host government and for implementing partners, compared with traditional outbreak and crisis response. It is important that routing WHO’s operating funds through government channels does not disincentivize WHO or other funding recipients from providing frank and candid technical and strategic guidance to a host government. Emergency business processes 38. Significant progress has been noted in emergency business processes, but considerable issues remain. The IOAC commends WHO for the rapid deployment of staff, timely provision of supplies, and disbursement of the CFE within 48 hours of requests to support field operations in multiple emergencies. For the ongoing Ebola response in the Democratic Republic of the Congo, over 500 staff were deployed through fast-track recruitment for surge capacity and US$ 4.5 million worth of supplies have been delivered through international procurement since 1 August 2018. The supplies include key operational necessities such as ambulances, personal protective equipment, infection prevention and control kits, syringes, freezers and other logistical requirements, amounting to 136 international shipments. The IOAC applauds WHO on increasing the logistics capacity in the Regional Office for Africa and the Regional Office for the Eastern Mediterranean. 39. The IOAC is encouraged to see that the WHE Programme is heavily engaged in redesigning supply chain business processes to support health emergency responses in the context of the transformation agenda. The IOAC recommends that the specialized expertise of the WHE Programme operations support and logistics team and the emergency management field experience should be leveraged within the transformation agenda and the effectiveness of operations should be maintained. 1 Strategic response plan for the Ebola virus disease outbreak, Democratic Republic of the Congo, 2018 (https://www.who.int/emergencies/crises/cod/DRC-ebola-disease-outbreak-response-plan-28May2018- ENfinal.pdf?ua=1&ua=1, accessed 19 April 2019). 2 PEF (http://www.worldbank.org/en/topic/pandemics/brief/pandemic-emergency-financing-facility, accessed 19 April 2019). Annex A72/6 11 40. The IOAC acknowledges that emergency measures under the Framework of Engagement with Non-State Actors have been published in the WHO eManual, section XVII, following the IOAC’s previous recommendation. However, the IOAC’s desk review on the Ebola response indicated that these measures are not being fully applied on the ground and the IOAC recommends that further efforts be carried out to streamline the process and accelerate engagement to support critical emergency responses. 41. The IOAC was briefed that a harmonized template for WHO Representatives’ (WRs’) DOA has been developed and that further guidance on implementation has been provided. The IOAC recognizes that DOAs to WRs for resource mobilization are being reviewed as part of WHO’s corporate transformation, with an initiative to harmonize approval levels across major offices. The IOAC will continue monitoring progress. International Health Regulations (2005) and health systems 42. As at March 2019, 95 countries have undertaken voluntary external evaluations of country preparedness; 52 National Action Plans for Health Security (NAPHSs) have been completed since February 2016. Evidence from the IOAC’s field visits to Uganda1 affirmed that external assessment using the joint external evaluation JEE tool was useful for identifying gaps and helped the country to rapidly implement measures when the EVD outbreak was declared near its border with the Democratic Republic of the Congo. The IOAC welcomes the fact that the WHE Programme has proposed a streamlined process of evaluations, development of NAPHSs and fundraising to accelerate the implementation of the NAPHS. The IOAC also endorses WHO’s approach to providing Member States with the flexibility to utilize their own country action plans where NAPHSs have yet to be developed. 43. During the field visits to Uganda, the IOAC took note of the appreciation expressed by the government and donors for WHO’s support for the Ebola readiness and preparedness work. The IOAC congratulates WHO on the updated WHO Regional Strategic Plan for EVD Readiness Preparedness Plan in nine countries neighbouring the Democratic Republic of the Congo for the period from January to June 2019. The IOAC notes the trade-off between emergency response and preparedness efforts. The IOAC recommends that WHO support countries in maintaining the level of preparedness and avoiding burnout after Ebola readiness efforts. 44. The IOAC noted that approximately US$ 42 million has been mobilized for EVD preparedness work since May 2018, including US$ 10 million in first-time Central Emergency Response Fund (CERF)2 awards for early action, but that a budget gap of US$ 27 million remains. More than 40 staff members are currently being deployed to support Ebola readiness and preparedness in four priority countries. The IOAC recognizes WHO’s efforts and investment in this important area of work but warns that this is not sustainable long term. Given that the WHE Programme is facing a funding shortage for the Ebola response and that there are other grade 3 crisis responses ongoing, including the response to Cyclone Idai in Mozambique, the IOAC reiterates the need to build national capacity and recommends that WHO continue to work with Member States and partners to build International Health Regulations (2005) (IHR) core capacities. The IHR requirements are a foundation for health systems and health security and the WHE Programme should ensure that its work is integrated within an overall approach to strengthening health systems. 1 Uganda mission report (https://www.who.int/about/who_reform/emergency-capacities/oversight-committee/uganda- mission-report-2018.pdf?ua=1, accessed 19 April 2019). 2 CERF (https://cerf.un.org/, accessed 19 April 2019). A72/6 Annex 12 CONCLUDING REMARKS 45. The IOAC welcomes the efforts of the Director-General, the senior leadership and WHO staff in beginning to transform the whole Organization to meet the ambitious triple billion targets of the Thirteenth General Programme of Work. The IOAC endorses the strategic direction WHO has taken, with a shift of the narrative from the WHE Programme to WHO’s function in emergencies. The IOAC will closely monitor the process of harmonizing cross-cutting functions to ensure that the transformation agenda can provide added value to the Organization’s key priority of managing emergencies. The IOAC will also track how effectively WHO manages the risks inherent in such a change on their ongoing ability to respond to emergencies. 46. WHO has established a strong coordination and leadership role in health. Two EVD outbreaks in the Democratic Republic of the Congo subsequent to the West African outbreak have demonstrated WHO’s progress as both an operational and technical organization leading the response at the front line. The declining trend of the current EVD outbreak, noted by IOAC in its report to the Executive Board at its 144th session in January 2019, has been reversed and transmission is increasing as of the writing of this report. The Ebola virus has since spread southwards of the provinces of North Kivu and Ituri amid protracted armed conflict. The IOAC commends WHO’s reaffirmed commitment to ending the outbreak. However, the IOAC is very concerned about funding gaps and staff exhaustion due to prolonged operations in a highly insecure and complex setting. The current EVD outbreak in the Democratic Republic of the Congo is at a critical juncture and WHO cannot succeed without the assistance of, and collaboration with, its partners and without financial support from Member States and donors. Felicity Harvey (Chair), Walid Ammar, Hiroyoshi Endo, Geeta Rao Gupta, Jeremy Konyndyk, Precious Matsoso, Theresa Tam = = =