Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme: looking back to move forward

SEVENTY-THIRD WORLD HEALTH ASSEMBLY A73/10 Agenda item 13.1 4 November 2020 Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme Looking back to move forward PART 1. BACKGROUND 1. The Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC)1 was established in 2016, following the West Africa Ebola virus disease outbreak, to provide independent scrutiny of the implementation of WHO’s reform of its work on outbreaks and emergencies, and its ongoing health emergency management. For the purposes of this report, the IOAC decided to look back on the 2016 reform, review progress made over the past four years, and identify the lessons learned that could be useful going forward, especially in the light of the ongoing pandemic of coronavirus disease (COVID-19). 2. The Ebola virus disease outbreak in West Africa during 2013–2016 was the largest and most complex Ebola virus disease outbreak since identification of the virus in 1976. It claimed more than 11 000 lives and caused major socioeconomic disruption in the region. The crisis exposed organizational failings in WHO’s health emergencies management and shortcomings in the International Health Regulations (2005) (IHR). The Organization’s performance was widely reviewed both during and after the crisis by various individual experts and groups, including the United Nations High-level Panel on the Global Response to Health Crises,2 the Ebola Interim Assessment Panel,3 and the Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies with Health and Humanitarian Consequences. WHO was urged to undertake major transformation in order to strengthen its organizational capacity to respond to outbreaks and other emergencies, and to restore trust and confidence in its ability to protect global health. 3. WHO Director-General Dr Margaret Chan submitted a report on the reform of WHO’s work in health emergency management to the Sixty-ninth World Health Assembly, document A69/30,4 giving an overview of the design, oversight, implementation plan and financing requirements for the new WHO Health Emergencies (WHE) Programme. Development of the WHE Programme was founded upon the 1 For more information, see the IOAC website: https://www.who.int/about/who_reform/emergency- capacities/oversight-committee (accessed 28 September 2020). 2 See https://www.un.org/press/en/2015/sga1558.doc.htm (accessed 19 October 2020). 3 Report of the Ebola Interim Assessment Panel, Geneva: World Health Organization; 2015 (https://www.who.int/csr/resources/publications/ebola/ebola-panel-report/en/, accessed 28 September 2020). 4 Document A69/30 (https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_30-en.pdf, accessed 19 October 2020). A73/10 2 principles of a single programme across all three levels of the Organization, with one clear line of authority, one workforce, one budget, one set of rules and processes, and one set of standard performance metrics, to bring speed and predictability to WHO’s emergency work. The Sixty-ninth World Health Assembly decided to establish the WHE Programme,1 which was officially launched on 1 July 2016, with an overall budget of US$ 494 million for the 2016–2017 biennium. 4. To monitor implementation of the reform, the IOAC developed a monitoring framework as indicated in document A69/30. That framework, which is regularly updated, has been further refined in line with the Thirteenth General Programme of Work, 2019–2023 and the WHO transformation agenda. The IOAC has previously submitted seven reports presenting its findings and recommendations to the WHO governing bodies, as well as an interim report on WHO’s response to COVID-19 from January to April 2020, and a special report on WHO’s diversity and grievance system.2 Further field mission reports from country visits to Bangladesh, Colombia, the Democratic Republic of the Congo, Iraq, Mali, Nigeria, Pakistan, Turkey, Uganda and Viet Nam have also been made public. For this eighth report, the IOAC has produced a tabular summary of document A69/30, as well as a list of previous IOAC recommendations, tracking progress in their implementation over the 2016–2020 period. Both are published on the IOAC website together with an updated monitoring framework. PART 2. OVERALL PROGRESS 2016–2020 AND THE STATUS OF THE WHO HEALTH EMERGENCIES PROGRAMME 5. The establishment of the WHE Programme marked the determination of Member States to reform their Organization and reinforced the Secretariat’s concerted efforts to transform WHO into a global leader in public health with both normative and operational capacities, equipped to manage outbreaks and emergencies on the ground, and to fill a critical gap in global health by providing preparedness, readiness, response and recovery activities. 6. The WHE Programme was launched in line with decision WHA69(9) and the Organization has made substantial progress in health emergency management. Over the past four years, WHO’s leadership effectiveness in the global response to health emergencies has consistently improved in both acute and protracted crises. Since the launch of the WHE Programme, WHO has managed up to 500 events annually based on an all-hazards approach. WHO senior leadership deserve credit for this progress, including former Director-General Dr Margaret Chan, who initiated WHO’s emergency reform; the late Dr Peter Salama, who led the implementation of the WHE Programme reforms for the first two and a half years; and the current leadership of WHO, who have continued to implement and build on the 2016 reforms. 7. Desk reviews, field visits, surveys and interviews conducted by the IOAC consistently find that the 2016 emergency reform and the establishment of the WHE Programme have raised WHO’s profile as an operational entity leading health emergency activities in the field. The IOAC notes that an incident management system has been institutionalized within the WHE Programme founded on a “one programme” approach. There is a general perception among staff that coordination across the three 1 Decision WHA69(9) (2016). 2 Special report to the Director-General of the World Health Organization (https://www.who.int/about/who_reform/ emergency-capacities/oversight-committee/ioac-special-report.pdf?ua=1, accessed 19 October 2020). A73/10 3 levels of WHO has significantly improved. Nevertheless, the IOAC observes that the organizational culture and administrative system continue to resist change. 8. In 2017, the newly-appointed Director-General, Dr Tedros Adhanom Ghebreyesus, laid out WHO’s strategy in the Thirteenth General Programme of Work, 2019–2023,1 emphasizing harmonized organizational transformation aimed at greater efficiency, better coordination and enhanced transparency, while placing WHO’s work in emergencies as a top priority. Implementation of the WHO transformation agenda has continued amidst the COVID-19 pandemic, but the IOAC notes that the centralizing of business processes, such as human resource management and other cross-cutting functions, has yet to fully deliver on its ambition of greater efficiency and organizational cohesiveness. WHO health emergency management: roles and responsibilities in emergencies and accountability 9. The West Africa Ebola virus disease crisis revealed the critical importance of clarifying WHO’s role and responsibilities in emergencies and its accountability. In response, in 2017, the WHO Secretariat published the second edition of the Emergency Response Framework (ERF),2 to articulate WHO’s obligations under the IHR, and within the global humanitarian system as the lead agency of the Inter-Agency Standing Committee’s Global Health Cluster. The ERF also sets out a common approach for risk assessment, the WHO grading of public health events and emergencies, the incident management system, emergency performance standards with key indicators, and the emergency response procedures. The IOAC acknowledges that adherence to the ERF has been increasingly consistent in major emergencies and has enhanced coordination between the three levels of the Organization. However, while the Framework has proved effective in management of acute outbreaks, it requires further adaptation for protracted crises. 10. The ERF places ultimate authority for WHO’s work in emergencies with the Director-General, but accountabilities and operational responsibilities for the speed and effectiveness of responses are delegated to Regional Directors and the WHE Executive Director, according to grade level and type of emergency. The IOAC observes that graded emergencies are managed collectively and in a coordinated fashion across the three levels of the WHE Programme, regardless of the ERF classification. That is mainly due to the strong, cordial working relationships between the Regional Directors and the WHE Executive Director, and to a professional commitment by managers at all levels to being accountable to the populations they serve, Member States, partners and donors. Significant improvement has been made in internal coordination mechanisms, management structures and decision-making processes. However, ambiguity remains in the ERF and in the implementation of shared accountability, roles and responsibilities, delegation of authorities and reporting lines between the Director-General, the Regional Directors, the WHE Executive Director, the Regional Emergency Directors, WHO representatives, and incident managers. 11. While the 2016 emergency reform proposal was seen as headquarters-centric, the WHE Programme has strengthened WHO country offices and helped regional offices to play a stronger role in coordinating regional platforms and in providing important insights into the geopolitical issues in the respective regions that impact WHO’s emergency response. The elected Regional Directors are accountable to the Member States of their respective regions and for day-to-day management of staff at the country and regional levels and for national and regional infectious disease outbreaks. Equally, the 1 Thirteenth General Programme of Work, 2019–2023, World Health Organization: Geneva; 2019 (https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf, accessed 4 October 2020). 2 See https://www.who.int/hac/about/erf/en/ (accessed 19 October 2020). A73/10 4 WHE Executive Director is accountable for WHO’s corporate performance in outbreaks and emergencies and for early detection, containment and response at the country and regional levels because, as seen in the West Africa Ebola virus disease crisis and the COVID-19 pandemic, an international spread of any infectious diseases starts from a small cluster of local outbreaks. Given the nature of infectious diseases, it is imperative that the joint accountability of the Regional Directors and the WHE Executive Director for infectious disease outbreaks be ensured, with dual reporting lines to them for Regional Emergency Directors and relevant staff across three levels. The ERF should further clarify the roles and specific responsibilities of each office embedded in the WHE programme and reinforce institutional measures required for rigorous compliance therewith, providing a single line of authority in case of disagreement. 12. The adherence to the accountability framework depends to a large extent on how much managerial authority the WHE Programme has within the Organization. In 2016, when the Programme was launched, its independent single budget, staffing and workplan were under the responsibility of the Executive Director, in consultation with the Regional Directors. Throughout implementation, each major office adjusted its workplan and adapted the WHE structure according to needs. Over the past four years, the WHE Programme has matured and its challenges and opportunities have evolved. Under the Thirteenth General Programme of Work, 2019–2023, and the WHO transformation agenda, thought has been given to integrating the WHE Programme into the rest of the WHO structure, to ensure that other parts of the structure can better engage with the WHE Programme and leverage WHO’s emergency work, while simultaneously giving the WHE Programme the benefit of improved linkages with all levels of the Organization. 13. The IOAC emphasizes that WHO’s work in outbreaks and emergencies must be reflected in every aspect of the Organization as a core part of its mandate. While the WHE Programme is not a stand-alone entity and its success depends on operational support systems and other programmes, the IOAC cautions WHO to find the right balance between autonomy and integration of the WHE Programme and make the required institutional arrangements to safeguard the WHE Programme’s managerial authority and autonomy against politicization. The IOAC reiterates that WHO’s work in outbreaks and emergencies must continue to adhere to humanitarian principles with great focus on impartiality, neutrality, and political independence. WHO administrative systems and emergency support operations 14. Delivering an effective emergency response requires an agile administrative system, standardized procedures and streamlined business processes. The West Africa Ebola virus disease outbreak starkly revealed WHO’s shortfalls in this regard. The 2016 reform therefore recognized administration and support systems as core functions of the WHE Programme and included a dedicated business process for managing human resources, finances, procurement and logistics in support of WHO’s emergency response, aspiring to a “no-regrets” approach. Great efforts were made by the Secretariat to introduce new ways of working by embedding the emergency business rules into the WHO e-manual, but feedback from staff and partner organizations indicated that major constraints remained that affected the agility and effectiveness of emergency operations. 15. The delegation of authority (DOA) in emergencies was standardized across the regions in 2017. Further guidance on DOA implementation in the Global Management System (GSM) was released in line with the WHO transformation agenda to streamline the process and harmonize approval levels across major offices. However, the application of such authority has been inconsistent due to a risk- averse organizational culture and lack of understanding by the staff involved in the process. A73/10 5 16. Under the leadership of Director-General Dr Tedros, the WHE Programme was made an organizational priority in the WHO transformation agenda. The transformation agenda acknowledged the urgent need to improve the administrative system and business processes that underlie WHO’s emergency work. It has sought to find solutions at a corporate level by centralizing critical enabling functions, such as communications, resource mobilization, human resources, procurement and security, as well as by consolidating structures across the Organization. The IOAC cautions that such centralization could dilute the WHE Programme’s distinctive functions and agile business processes.1 17. It is too early to assess the full impact of the centralization on the WHE Programme but the IOAC observes that the Department of Coordinated Resource Mobilization (CRM) has demonstrated its potential in WHO’s response to COVID-19. Close collaboration and interaction between the leaderships of the WHE Programme and CRM, extensive consultation and negotiation processes to set common objectives, priorities and division of labour, and dual reporting lines for CRM staff to the WHE Programme as well as the head of CRM, have mobilized substantial financial resources and have built donor confidence. The IOAC recognizes that the expertise in emergency-specific resource mobilization is fully embedded in CRM and the entire department is ready for repurposing its workforce to respond to major crises. The IOAC also observes that the success of the centralization of the resource mobilization function relies heavily on the good interpersonal working relationship between the Executive Director of the WHE Programme and the Executive Director for External Relations and Governance, and the commitment of their staff. 18. In March 2017, the IOAC conducted field missions in Iraq, where it observed the frustration of WHO country office staff faced with an average of 87 days taken to fill new positions, from the initiation of the process to the new staff member arriving at the duty station. However, an IOAC mission to the Democratic Republic of the Congo in May 2019 indicated that the reform had impacted positively on human resources management. As of 29 April 2019, 745 people had been deployed to the field, including 650 who were recruited on consultancy contracts through a fast-track recruitment process for surge capacity. The WHE Programme’s dedicated human resources team managed to issue consultancy contracts within 24 hours for emergencies, and temporary staff contracts in seven days for emergencies. Under the transformation agenda, the WHE Programme human resources function was centralized and the standard operating procedures are being restructured and further developed. Although there is a team designated to support emergencies in the Department of Human Resources, the WHE Programme perceives that human resources processes have become lengthier and more cumbersome, with additional layers of review for recruitment. 19. Both WHO staff and partners consistently point to a critical gap in the procurement system and supply chain management of the Organization. Findings suggest that persistent delays in procurement and delivery erode partners’ confidence in WHO’s capacity and accountability on the ground. As part of the transformation agenda, WHO General Management (GMG) and departments across the Organization, including the WHE Programme, are working together on building a fit-for-purpose supply chain that should provide the support required for health emergencies. 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 notes that the WHE Programme established the COVID-19 Supply Chain Inter-Agency Coordination Cell, composed of staff from WHO, the United Nations Office for the Coordination of Humanitarian 1 See document A72/6 (https://www.who.int/about/who_reform/emergency-capacities/oversight-committee/A72-6- en.pdf?ua=1, accessed 20 October 2020). A73/10 6 Affairs and the United Nations World Food Programme, to help respond to the COVID-19 pandemic. 20. Following the centralization of the communications function, the WHE Programme continues to work closely with a fully dedicated emergencies team within the Communication Department under the Office of the Director-General. The COVID-19 pandemic has added momentum, accelerating the establishment of a corporate communication strategy, improving public communication, and increasing WHO’s global visibility. While the IOAC recognizes the significant progress made, further improvement is required in terms of accountability to, and coordination with, the WHE Programme, the External Relations Division and the rest of the Organization at all three levels, to maximize available resources and ensure consistent messaging for major emergencies. WHE budget and financial management 21. For the 2016–2017 biennium, WHO allocated a budget of US$ 334 million for its emergency work and requested an additional US$ 160 million in core funding for activities and staff that would be transitioned under the emergency reform. On 1 July 2016, the WHE Programme was launched with a total budget of US$ 494 million. As of November 2019, the Programme was funded to about 90% of its core budget of US$ 533 million for the 2018–2019 biennium. While recognizing the WHE programme’s improved ability to fundraise, the IOAC expressed its concerns about the reduction of WHO core flexible funding allocated to the WHE Programme. WHO is encouraged to increase allocation of the core flexible funding for the WHE Programme, in particular supporting countries with preparedness activities, for which it has proved difficult to raise funds. The WHE Programme budget has only risen 7% over the last four years. The IOAC considers this increase is inadequate in view of the increasing demands now being made on the WHE Programme’s responses to emergencies and humanitarian crises. Moreover, a budget of that size is insufficient to deal with a global pandemic like COVID-19. 22. While the core budget remained modest from 2016 to 2020, the IOAC observes great improvement in the financial support for appeals as the WHE Programme’s successful field performance has boosted humanitarian donors’ confidence in WHO. During the 2016–2017 biennium, US$ 780 million of the total appeal for US$ 1073 million for humanitarian response was received and directed towards graded emergencies. The WHE Programme reported a funding gap of only 6% of the total estimated requirement of US$ 1.2 billion for the 2018–2019 biennium. The IOAC observes that although WHO country office capacity for emergencies has been strengthened in the priority countries, challenges persist in fundraising at country level. 23. In 2019, the Contingency Fund for Emergencies (CFE) raised US$ 54 million from 16 donor countries. There is wide recognition by Member States that the CFE is critical in enabling WHO to address immediate needs in emergencies, thus preventing the further spread of an outbreak. However, the Fund struggled to reach the total capitalization set at US$ 100 million, and the replenishment mechanism has proved ineffective. The IOAC also observes that the CFE was disbursed for purposes other than those intended, for example to remedy a severe cash flow problem in the Ebola virus disease response in the Democratic Republic of the Congo, seriously depleting its balance. The IOAC held an interview with CFE donor countries, in which Member States questioned the sustainability and transparency of the CFE, and the application of rigorous criteria for its use. They informed the IOAC that the ad hoc nature of funding requests was problematic from their perspective, and that a broader donor base was needed, with more donors and a more diversified funding stream. The donor countries also noted a lack of coordination among the international financing mechanisms for emergencies, such as the Pandemic Emergency Financing Facility and the Central Emergency Response Fund. A73/10 7 24. Overall, WHO has proved its capacity to raise funds to manage emergencies, and the WHE Programme has steadily gained donor trust. However, the IOAC observes that there is a significant discrepancy between Member States’ financial contributions and their expectations of the WHE Programme. The result is a constant struggle to mobilize resources, with staff forced to juggle competing priorities simultaneously. The Organization faces chronic financial challenges: lack of predictable and flexible funding, competing priorities, heavy dependence on a limited number of donors and donor fatigue. Furthermore, as WHO’s role grows in major emergencies the risks inherent in operating in fragile states have significantly increased, as seen from the allegations against the WHO country office in Yemen in 2018. The IOAC notes that the Secretariat has developed a management action plan to improve the Yemen country office’s capacity and effectiveness in finance and administration for full implementation by the end of 2020. The IOAC stresses that ensuring that the WHE Programme operations are transparent and free of collusion, fraud and corruption, is of paramount importance. WHE Programme workforce 25. In November 2016, a total of 1396 positions were planned for the WHE Programme across the Organization, with a proposed distribution of 50% at country level, 25% across the six regional offices and 25% at WHO headquarters. As at November 2019, the total number was increased to 1583 positions with a distribution of 46% in country offices, 30% across the six regional offices and 24% at WHO headquarters. Currently, WHE Programme staffing stands at 1064, with 519 positions vacant mainly due to insufficient funding. About 70% of the planned positions in the country offices have been filled. An IOAC survey with WHO representatives confirmed that the WHE Programme has strengthened the human resources capacity of WHO country offices. However, WHO representatives say that the workforce at country level is spread thin and that the COVID-19 pandemic has shown that the country business model needs to be revised. 26. The IOAC observes important improvement in WHO’s health cluster coordination and leadership in protracted emergencies. However, little progress has been made in the staffing of health cluster positions over the last four years. As at December 2019, six out of 30 health clusters did not have a dedicated health cluster coordinator, but rather a staff member working as coordinator on a part-time basis and fulfilling other functions in the WHO regional or country office. Only 14 of the clusters had dedicated information management officers, and those were mostly on short-term contracts linked to event-based funding or deployed through standby partners. Lack of suitable candidates and paucity of funding are among the obstacles. Consideration should be given to improving the recruitment modalities and selection process to find candidates with skill sets that match specific country needs, to developing an internal roster system for potential health cluster coordinators and information management officers, and to upgrading the training, orientation and empowerment of health cluster coordinators. 27. The COVID-19 pandemic has shown the world the importance of WHO’s core normative and policy-setting functions and has revealed the need to strengthen the capacity and expertise of the WHE Programme workforce in both infectious diseases and social science. Existing in-house expertise should also be leveraged, through surge capacity or repurposing, to support emergency responses. Findings from the IOAC interim report on WHO’s response to COVID-191 suggest that the WHE Programme should further leverage WHO collaborating centres, expert networks such as technical 1 See https://www.who.int/about/who_reform/emergency-capacities/oversight-committee/IOAC-interim-report-on- COVID-19.pdf?ua=1 (accessed 20 October 2020). A73/10 8 advisory bodies, and public health institutes, in order to maintain a balance between technical rigour and rapid policy guidance. 28. The WHE Programme has operated under constant emergency conditions since its launch in 2016, with obvious concomitant pressure on Programme staff. The IOAC considers that special consideration should be given to the recruitment and career progression of staff working in emergencies at extreme hardship duty stations. The IOAC observes that implementation of the WHO transformation agenda has led to good progress in staff development, learning and rewards for top performers, with commensurate incentives for staff under exceptional working stress. However, talent acquisition, retention and performance management are still a cause for concern and need to be strengthened. 29. During its field visits, the IOAC noted serious gaps in WHO security capacity and management as well as in staff protection measures. In its previous reports, the IOAC has repeatedly recommended that WHO make corporate investments in its own security capacity when implementing the WHE Programme. The IOAC is concerned that the recruitment of WHO security at WHO headquarters is still incomplete and that the position of the head of the WHO security services has been downgraded from D1 to P5. It is also unclear how WHO security functions in terms of line reporting, accountability and coordination across field, country and regional offices and WHO headquarters. Insecurity continues to expose WHO staff working on the ground to high risk, hindering effective response in the affected communities. 30. In implementing the 2016 reform, the urgency to absorb all staff members from the pre-existing departments working in emergencies and merge them together to roll out the WHE Programme prevented the Organization from fully ensuring gender balance, diversity, inclusiveness, and from establishing an appropriate grievance and redress system. In February 2019, in response to anonymous allegations that the WHE Programme had shortcomings in some of these areas, the Director-General mandated the IOAC to review issues impacting on staff morale and impeding the Programme from performing optimally. The IOAC’s review concluded that these issues pertained equally to all of WHO and the Regional Offices as they did to the WHE Programme, and recommended a series of Organization-wide measures. The IOAC is pleased to see the improvement in human resources diversity of the WHE Programme but concerned that little progress has since been made with the organizational policy and systems. The IOAC also notes that the investigation into the allegations has yet to be completed, while the reputation of the Programme staff cited in those allegations remains seriously compromised. Partnerships 31. Over the last four years, the WHE Programme has made steady progress in strengthening its relationship with Member States and other traditional stakeholders, expanding partnerships with civil society and the private sector, and affirming its role in the major partnership platforms for both humanitarian and public health emergencies. In responding to COVID-19, WHO has convened global experts and put in place numerous initiatives and platforms such as the Solidarity trial1 and the Access to COVID-19 Tools (ACT) Accelerator.2 1 For more information, see: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on- novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments (accessed 29 September 2020). 2 For more information, see: https://www.who.int/initiatives/act-accelerator (accessed 29 September 2020). A73/10 9 32. Findings from the IOAC field visits confirmed that operational partnerships and WHO’s leadership role within the humanitarian architecture have also improved greatly. However, the IOAC observes that WHO’s performance in the health cluster and interaction with partners in the field relies heavily on the individual ability of health cluster coordinators. Systematic measures and institutional support for health cluster coordinators are needed to ensure that WHO provides strong coordination and technical and operational support to partners on the ground through the health cluster system. 33. WHO has performed its role as the United Nations agency specialized in health, leading the United Nations Crisis Management Team (UNCMT) for COVID-19. The UNCMT, activated on 4 February 2020, coordinates the entire United Nations system to support countries in responding to the COVID-19 pandemic. It has brought both humanitarian and development partners together under WHO’s leadership and has become an important coordinating network for the global humanitarian response to COVID-19, facilitating implementation of WHO recommendations in low-resource settings and mitigating the socioeconomic impacts of the pandemic in fragile states. The IOAC notes positive feedback and recognition from United Nations partners on the WHO’s leadership at both the global and field levels. 34. The IOAC also recognizes the sustained efforts of the WHE Programme to engage with and build the depth and capacity of WHO partner networks, such as the Global Outbreak Alert and Response Network (GOARN), the Emergency Management Team (EMT) and Standby Partnership Agreements, to leverage and increase the pool of expertise and resources across a range of hazards. Further clarity on the governance structure of WHO partnerships, roles and responsibilities, and coordination mechanisms is however required. Research and Development 35. As part of the 2016 reform, WHO convened a broad global coalition of experts to develop the blueprint and a platform for accelerated research and development to ensure the rapid activation of research and development activities during epidemics (the R&D Blueprint).1 The work of the R&D Blueprint supported the introduction in 2018–2019 of four new therapeutics for case management and large-scale vaccination against Ebola virus in the Equateur and Kivu provinces of the Democratic Republic of the Congo. The IOAC was briefed that in response to COVID-19, the R&D Blueprint facilitated the process of multinational vaccine and therapeutic drug trials by standardizing the protocols and leveraging national capacities. The R&D Blueprint is managed jointly by the WHE Programme and the Science Division, with centralized resource mobilization. Although no accountability framework is in place, the R&D Blueprint has performed well, in part as a result of the personal commitment of, and cordial relationship between, the Chief Scientist and the WHE Executive Director. 36. The COVID-19 pandemic has accentuated WHO’s core normative and standard-setting role more clearly than ever. The creation, under the transformation agenda, of a new Science Division has proved particularly useful in supporting the Organization’s mandate during the pandemic. The IOAC observes that the Science Division works closely with the WHE Programme in ensuring medical and scientific rigour in the COVID-19 response by leveraging WHO research platforms and by establishing a publication review committee, co-chaired by senior staff from the WHE Programme and the Science Division. 1 See the Global Observatory on Health R&D (https://www.who.int/research-observatory/analyses/rd_blueprint/en/, accessed 29 September 2020). A73/10 10 37. The level of global collaboration throughout the research community and willingness to share findings on COVID-19 is unprecedented. In view of the urgency of finding effective treatment and vaccines over the coming year, the IOAC will scrutinize WHO’s performance in providing a platform, facilitating research activities and accelerating the development and manufacture of COVID-19 vaccines, and in guaranteeing fair and equitable access for all countries of the world. International Health Regulations (2005) 38. The COVID-19 pandemic has raised fundamental questions regarding the appropriateness of the current provisions of the IHR, and the effectiveness of existing mechanisms and tools in preventing the international spread of disease. In its interim report on COVID-19, the IOAC recommended revisiting the duties of Member States and the roles and responsibilities attributed to the WHO Secretariat under the IHR. The IOAC reiterates that the WHO Secretariat’s actions are grounded in its duties and responsibilities under the IHR and Member States’ compliance with the IHR in their own response to crises, which should be considered in reviewing WHO’s response to COVID-19. 39. The IOAC notes that WHO’s core IHR function was assimilated into the WHE Programme structure. Between 2016 and 2019, with the goal of building national capacities to prevent, detect and rapidly respond to public health threats, the WHO Secretariat supported more than 100 countries in undertaking joint external evaluations (JEE) across the regions, and assisted 65 countries in completing their national action plans for health security. While recognizing the progress made, the IOAC cautions that investment in preparedness has been insufficient and the impact of WHO’s action on strengthening IHR core capacities is unclear. 40. The IOAC interim report on WHO’s response to COVID-19 noted that the majority of countries appeared ill-prepared, indicating no clear relation between the JEE score and the actual country preparedness and response in the event of a pandemic of this scale and magnitude. The IOAC emphasizes that supporting Member States in building IHR core capacities is one of the WHE Programme’s prime functions and the Secretariat should review existing tools and mechanisms in the light of COVID-19 and the lessons learned. In that connection, national leadership, a whole of government approach, subnational level capacity, and community empowerment and resilience should all be considered. 41. The West Africa Ebola virus disease crisis raised issues related to the declaration of a public health emergency of international concern (PHEIC), highlighting the international community’s lack of understanding of the meaning of a PHEIC. The Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response discussed the possibility of an intermediate level of declaration, but the determination of a PHEIC has remained a binary decision. The IOAC considers it opportune to introduce a graded system with clear criteria and practical implications for countries, to make it possible to alert and engage the wider international community at an earlier stage in a health crisis. Part 3. The way forward: Recommendations 42. Since the inception of the WHE Programme, the IOAC has monitored the implementation of the 2016 reform with regard to the Programme and provided oversight of the Programme’s work in outbreaks and emergencies, reporting regularly to the WHO governing bodies with its findings and recommendations. On completion of its second, two-year term of office, the IOAC conducted a four-year review of the implementation of its previous recommendations. Overall, the IOAC is satisfied with the achievements made and impressed by the Secretariat’s dedication and tireless work to fully A73/10 11 realize the ambitions of the WHE Programme. The IOAC commends WHO for the very significant progress made in its work in acute emergencies and protracted crises, driven by strong leadership provided by the Director-General, the Regional Directors, and the WHE Executive Director. The IOAC reaffirms the observations made in its previous seven reports,1 and in its interim report on WHO’s response to COVID-19, and makes further recommendations on selected areas to complete the 2016 reform and provide future guidance for WHO’s emergency work, as follows: Recommendation 1. It is critically important to reiterate WHO roles and responsibilities in emergencies and institutionalize the implementation of already agreed managerial authorities and processes. The IOAC recommends that: (a) the agility and flexibility of the WHE Programme be further improved through an appropriate level of autonomy and authority based on the principle of a single structure, single budget, single staff workplan and common results framework across WHO headquarters and all regional offices. Managerial responsibility of the WHE Programme rests with its Executive Director, who reports directly to the Director-General; (b) the second edition of the ERF be updated with explicit roles and responsibilities given to each player and updated processes for all-hazards emergency risk management both for acute event management and protracted crises; (c) both the Regional Directors and the WHE Programme Executive Director share accountability for infectious hazard events and other health emergencies with potential to spread internationally. They share responsibility for day-to-day management of those events. The roles, responsibilities and accountabilities of each player and updated processes for all-hazards emergency risk management should be enshrined in the ERF; (d) Regional Emergency Directors be recruited and appointed jointly by the Regional Directors and the WHE Programme Executive Director. If there is disagreement, the decision lies with the Director-General. Regional Emergency Directors should have delegated authority for emergency management in their respective regions and report directly to the Regional Directors and the WHE Programme Executive Director; and (e) a formal dialogue take place to find an appropriate mechanism/platform that could facilitate engagement of Member States with the WHO Secretariat in order to achieve the Thirteenth General Programme of Work, 2019–2023 target of one billion more people better protected from health emergencies and to ensure alignment between Member States’ expectations and the WHO’s authority and capacities to address emergencies through the WHE Programme with shared accountability. Such a platform should also institutionalize activities for preparedness and response to emergencies and promote Member States’ compliance with the IHR. Recommendation 2. WHO systems and processes in administration, grant management, human resources management, and procurement should enable the WHE Programme to deliver an effective emergency response on the ground. The centralization of enabling functions must ensure the agility, flexibility and effectiveness of the WHE Programme. The IOAC recommends that: 1 Documents EB140/8, A70/8, EB142/8, A71/5, EB144/8, A72/6 and EB146/16 (https://apps.who.int/gb/gov/, accessed 26 October 2020). A73/10 12 (a) key performance indicators be established for all centralized functions (human resources, communication, resource mobilization, procurement, and security) to track their impact on WHO emergency operations. Such indicators should be set jointly by the WHE Programme and the respective divisions, and periodic reports should be submitted to the IOAC; (b) dedicated teams within the centralized functional divisions be put in place to support emergencies, with a dual reporting line to the WHE Programme and respective division heads; (c) the WHE Programme leverage the WHO transformation agenda to promote a “no regrets” approach to WHO’s emergency response across the Organization for all operational functions and administrative systems, in particular supply chain management; and (d) WHO make corporate investments in its own security function with a clear accountability framework including a dual reporting line, and coordination mechanism across field, country and regional offices and WHO headquarters for WHO security functions. Insecurity continues to expose WHO staff working on the ground to high risk, severely hindering effective response in affected communities. Recommendation 3. Predictable and flexible funding is critically important for the WHE Programme to continue to carry out strategic activities for strengthening country preparedness and to quickly implement all the necessary interventions for acute emergencies. WHO’s ability to raise funds for emergencies continues to rely on the value for money that the WHE Programme has managed to prove over time. The WHE Programme’s aspiration should be commensurate with Member States’ commitment to contribute. The IOAC recommends that: (a) Member States be invited to consider an increase in assessed contributions. This would allow the Director-General to enhance the sustainability and funding predictability of the WHE Programme through increased allocation from WHO’s regular budget, while broadening the funding base and demonstrating greater global solidarity than relying mainly on voluntary contributions from a limited number of countries. The IOAC also recommends the increased proportion of WHO core flexible funding be allocated to the WHE Programme. The WHE Programme should likewise prioritize existing resources in a more efficient and transparent manner, articulating the linkages between resources and specific outcomes, identifying benchmarks to assess progress on deliverables, and establishing processes for the rigorous tracking of expenditures and reporting in a more comprehensive manner; (b) the relationships and division of labour between the CFE and other humanitarian funding streams that receive donor support in health emergencies be clarified. Clarifying which funds should be used and under what circumstances would help both WHO and donors plan emergency responses more efficiently and effectively; and (c) the CFE replenishment mechanism, disbursement criteria and operating processes be redesigned. Consideration should be given as to whether the CFE should be partly funded by the WHO core budget or whether alternative sources of funding, including from the private sector and foundations, should also be explored. Recommendation 4. The COVID-19 pandemic has highlighted the critical importance of WHO’s normative function. The IOAC welcomes the intense and increasing level of collaboration between the WHE Programme and the Science Division. The IOAC recommends that: A73/10 13 (a) the WHE Programme and the Science Division work with other divisions across the Organization to implement the R&D Blueprint’s joint workplan with funding requirements, a common monitoring framework and a system of dual reporting to the WHE Programme Executive Director and the Chief Scientist. Ultimately, the WHE Executive Director is accountable for the R&D Blueprint’s performance in emergency operations; (b) WHO strengthen the WHE Programme’s capacities in providing scientific advice and technical guidance and institutionalize the mechanism to prioritize areas needing urgent guidance and to fast track a review and publication process, which has been set up for a timely provision of guidelines on COVID-19. The WHE Programme is encouraged to enhance collaborations with the existing technical advisory bodies, such as the Strategic and Technical Advisory Group for Infections Hazards and GOARN, and further enhance partnerships with WHO collaborating centres, public health institutes and other technical and expert groups to improve scientific and technical rigour and timelines through rapid access to additional capacity; (c) WHO secure resources to maintain and increase core technical expertise capacity within the WHE Programme at WHO headquarters and enable the Programme to leverage in-house experts through internal surge capacity. Institutional measures and systems must be in place to ensure timely release of staff from other divisions as needed; (d) the WHE Programme take into account the socioeconomic and gender-related implications of preparing for, responding to, and recovering from public health emergencies and their interventions, by establishing a small dedicated team of social scientists and gender equality experts within the WHE Programme, guided by an external advisory group or expert network; and (e) WHO be actively involved in global efforts to promote equitable access to COVID-19 vaccines and treatments, and further recommends the continued active involvement of WHO in this process. Recommendation 5. Global health is a shared responsibility and Member States must play their part. The IOAC welcomes the establishment of the Independent Panel for Pandemic Preparedness and Response1 and the Review Committee on the Functioning of the International Health Regulations (2005) during the COVID-19 Response2 and affirms its commitment to supporting their ongoing work in this regard. The IOAC recommends that: (a) Member States ensure that their expectations of WHO are consistent with the authorities they grant to the WHO Secretariat, and that WHO be empowered to fulfil its role as recommended and restated in a new version of the IHR under guidance of the IHR Review Committee; (b) a graded PHEIC system with clear criteria and practical implications for countries be introduced, under the guidance and based on the recommendations of the IHR Review Committee, to facilitate preparedness, preventive action, and dedication of resources at the early stage of 1For further information, see: https://www.who.int/news-room/detail/09-07-2020-independent-evaluation-of-global- covid-19-response-announced (accessed 29 September2020). 2For further information, see: https://www.who.int/teams/ihr/ihr-review-committees/covid-19 (accessed 29 September 2020). A73/10 14 outbreaks, which could avert any escalation. The PHEIC grading must be tied to a set of binding actions under the IHR provisions; (c) the WHO Secretariat further streamline the reporting process and support countries in strengthening capacity to report on the information required under the IHR; (d) the adequacy of JEE and other existing tools to support country preparedness be reviewed based on the lessons learned during the COVID-19 pandemic preparedness and response efforts, and improved under the guidance of the IHR Review Committee; and (e) peer-review mechanisms, platforms and incentives be launched and anchored to the governing bodies structure in order to ensure transparency, avoid politicization, and promote the IHR and Member States’ compliance therewith. Concluding remarks 43. Over the last four years, the WHE Programme has demonstrated its capacity to manage multiple emergencies and has helped affirm WHO’s position as a global health leader. The Programme’s overall functioning has been marked by a high degree of operational success and WHO has proved to be a reliable and competent partner to governments, United Nations agencies, health cluster members, nongovernmental organizations and donors. But the COVID-19 pandemic has thrown the challenges faced by WHO in handling a global pandemic into stark relief and has placed the WHE Programme under global public scrutiny. It must be recalled that the 2016 reform and the launch of the WHE Programme represented a profound change for the Organization, based on hard lessons learned from the West Africa Ebola virus disease crisis. The current structure and design of the WHE Programme was shaped by that crisis; therefore, the Programme has the capacity to respond to multiple events across the world of similar severity and size, but not a global pandemic. In looking back at the genesis of the WHE Programme and examining its performance during the first few months of the COVID-19 outbreak,1 the IOAC confirms that the WHE Programme has achieved the milestones set in 2016, but it will be necessary for the Organization to undertake yet further reform to allow it to become the guardian of global public health. This, then, must be seen as a defining moment for global community health. The IOAC reaffirms its commitment to providing oversight and advice to ensure that the WHE Programme continues to progress in all its fields of work, both operational, technical and normative, to help allow WHO to fulfil its role in protecting the health of populations across the globe. Felicity Harvey (Chair), Walid Ammar, Hiroyoshi Endo, Geeta Rao Gupta, Jeremy Konyndyk, Precious Matsoso,2 Theresa Tam = = = 1IOAC interim report on WHO’s response to COVID-19 (https://www.who.int/about/who_reform/emergency- capacities/oversight-committee/IOAC-interim-report-on-COVID-19.pdf?ua=1, accessed 21 October 2020). 2 Precious Matsoso served as the Chairperson of the IOAC from May 2016 to May 2018, and as honorary member from May 2018 until August 2020 when she was nominated to serve as a panellist on the Independent Panel for Pandemic Preparedness and Response (https://www.theindependentpanel.org/panel-members, accessed 21 October 2020).