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

EXECUTIVE BOARD EB144/8 144th session 21 December 2018 Provisional agenda item 5.2 Public health 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 Executive Board at its 144th session the report submitted by the Chair of the Independent Oversight and Advisory Committee (see Annex). EB144/8 2 ANNEX REPORT OF THE INDEPENDENT OVERSIGHT AND ADVISORY COMMITTEE FOR THE WHO HEALTH EMERGENCIES PROGRAMME I. BACKGROUND 1. The Independent Oversight and Advisory Committee (IOAC) was established pursuant to decision WHA69(9) (2016)1 to provide oversight and monitoring of the WHO Health Emergencies (WHE) Programme. The WHE Programme was launched on 1 July 2016 as a determined effort to reposition WHO as a United Nations (UN) specialized agency with operational functions for managing health emergencies while maintaining technical expertise. 2. During 2016–2018, the IOAC assessed whether WHO’s reform in health emergencies was on track with respect to eight thematic areas: structure, human resources, incident management, risk assessment, business processes, partnerships, finance and International Health Regulations (2005) (IHR). Upon completion of its two-year term of office in May 2018, the IOAC submitted its final report2 to the Seventy-first World Health Assembly. In that report, the IOAC concluded that important progress had been made, but that major constraints remained on the performance of the WHE Programme. 3. On the basis of this conclusion, and after consultations with various stakeholders, the Director-General of WHO decided to continue the independent oversight and advisory function and announced a new IOAC membership3 for 2018–2020 at the Seventy-first World Health Assembly. Since that announcement, the IOAC has conducted three regular meetings and one field mission. 4. Having considered the WHE Programme’s progress made over the last two years and the strategic directions set out in the Thirteenth General Programme of Work (GPW 13)4 and the WHO transformation agenda, the new membership revised the IOAC’s terms of reference,5 scope of work and monitoring framework.6 The IOAC will continue to oversee the WHE Programme’s performance, and the areas recommended in document A71/5 will be kept under its review. However, during its next phase, the IOAC will focus on programmatic areas rather than issues related to processes or procedures, in particular WHO’s work to support countries in strengthening their IHR core capacities and health 1 See document WHA69/2016/REC/1 (http://apps.who.int/gb/ebwha/pdf_files/WHA69-REC1/A69_2016_REC1- en.pdf, accessed 10 December 2018). 2 See document A71/5 (http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_5-en.pdf, accessed 10 December 2018). 3 IOAC membership: http://www.who.int/about/who_reform/emergency-capacities/oversight- committee/members/en/, accessed 10 December 2018. 4 WHA71.1 (2018). http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_4-en.pdf?ua=1, accessed 10 December 2018. 5 TOR http://www.who.int/about/who_reform/emergency-capacities/oversight-committee/TORs.pdf?ua=1, accessed 10 December 2018. 6 IOAC Monitoring Framework, http://www.who.int/about/who_reform/emergency-capacities/oversight- committee/ioac-monitoring-framework-sep2018.pdf, accessed 10 December 2018. Annex EB144/8 3 systems to reduce the risk of emergencies, recognizing that the latter area is not entirely within the WHE Programme, but depends upon support from other departments in WHO. II. PROGRESS, CHALLENGES AND OPPORTUNITIES 5. The IOAC is encouraged that GPW13 confirms the WHE Programme as an organizational priority, and that the Director-General’s implementation of his triple billion targets includes a clear emphasis on addressing health emergencies. The IOAC notes that its own monitoring framework and the GPW 13 indicators1 for tracking the progress of the WHE Programme are aligned. 6. Since the launch of the WHE Programme in July 2016, important progress has been noted throughout the Programme at all levels of the Organization. The recent Ebola outbreaks in the Democratic Republic of the Congo provinces of Equateur and later of North Kivu have demonstrated that WHO’s health emergency management reforms have had significant positive impact. During the Ebola outbreaks in the Democratic Republic of the Congo in 2018, the IOAC observed strong coordination across the three levels of WHO (headquarters (HQ), Regional Office for Africa and country offices in the Democratic Republic of the Congo and border countries). WHO’s efforts since the 2014–2015 Ebola outbreak also reveal substantial progress achieved in leadership, operational capacity, technical expertise, the speed and scale of response, internal and external communication, partner coordination and donor confidence. WHO leadership and health emergencies management 7. The IOAC commends the Director-General, the Regional Directors, and the Deputy Director-General for the WHE Programme, for their leadership and commitment in reforming WHO’s work in emergencies. As at 21 November 2018, WHO is responding to multiple crises including 170 ongoing events and 41 graded crises,2 eight of which are graded level 3 crises, including Ebola in the Democratic Republic of the Congo. Significant improvement has been made in internal coordination mechanisms, management structures, communications and decision-making processes. 8. Based on evidence from its missions to Uganda3 and briefings from all levels in the Democratic Republic of the Congo, the IOAC noted that the procedures of the Emergency Response Framework have been well implemented in the field and that the Incident Management System (IMS) has become an integral part of the Programme. The IOAC observed that, in response to the current Ebola outbreak in the Democratic Republic of the Congo, the four levels of Incident Management Teams (IMTs) (HQ, regional office (RO), WHO country office (WCO) and locally in North Kivu) are working effectively, with clearly differentiated roles and responsibilities and clear coordination across WHO. 9. The IOAC acknowledges that the Delegation of Authority has been standardized across all regions, and includes WHO Representatives’ financial authority to accept funds. However, despite the 1 GPW 13 WHO Impact Framework, http://www.who.int/about/what-we- do/GPW13_WIF_Targets_and_Indicators_English.pdf?ua=1, accessed 10 December 2018. 2 WHO Graded emergencies http://www.who.int/emergencies/crises/en/, accessed 10 December 2018. 3 Uganda Mission report, http://www.who.int/about/who_reform/emergency-capacities/oversight-committee/uganda- mission-report-2018.pdf, accessed 17 December 2018. EB144/8 Annex 4 tools that are available under the Global Management System (GSM),1 the application of such authority has been inconsistent due to lack of understanding by the staff involved in the process and a continuing culture of risk-aversion amongst managers. The IOAC recommends that further efforts are made to promote Delegation of Authority, to familiarize all levels of staff with it and to empower WHO representatives and managers. 10. The Democratic Republic of the Congo declared its tenth Ebola outbreak in 40 years in the province of North Kivu on 1 August 2018. As at 20 November, 386 Ebola virus disease cases, including 219 deaths, had been reported in 11 health zones in North Kivu Province and three health zones in Ituri Province. The IOAC notes that it is the country’s largest-ever Ebola outbreak and that the situation remains dangerous and unpredictable. Over two decades of armed conflict and inter-communal violence have taken a toll at the epicentre of the Ebola outbreak. The IOAC recognizes that WHO is operating in one of the most hazardous and complex contexts, with determination and confidence to contain the outbreak. 11. The IOAC was impressed with the field epidemiological investigation to determine the infection source of cases not previously identified as contacts. However, the IOAC noted that the overall trends in case incidence reflect continued community transmission in several cities and villages in North Kivu. The IOAC recommends that WHO develop plans for sustaining and expanding the personnel pipeline, including via partners; develop contingency plans for substantially scaling up the response if the disease spread accelerates, particularly in large urban areas; and identify threshold indicators for triggering a scale-up, enabling scaling up to be done proactively. 12. Evidence collected from a desk review, interviews and field visits to Uganda and the border of the Democratic Republic of the Congo, makes it clear that WHO is positioned as a front-line agency, leading the field operations while providing technical guidance to partners. The IOAC applauds WHO for taking key actions, such as staff deployment, release of the Contingency Fund for Emergencies (CFE), technical support to establish Ebola treatment units, vaccination of contacts and front-line health care workers, and administration of therapeutics, within 10 days of the declaration of the outbreak in North Kivu province. The WHO no-regrets policy, its increased operational capacity and technical leadership, are highly appreciated by the partners on the ground. 13. The IOAC recognizes WHO’s crucial role in implementing use of experimental Ebola vaccines2 and investigational therapeutics under the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI) protocol.3 The availability of vaccines and therapeutics are welcome innovations in the control of this Ebola outbreak. Between 1 August 2018, when the Ebola outbreak was declared, and 15 November 2018, 275 rings were defined and about 42 000 eligible and consenting people were vaccinated, including 14 000 health care workers. In addition, 203 patients received therapeutics under the MEURI protocol in four Ebola treatment centres, free of charge. Concerns about the limited quantity of the experimental Ebola vaccine currently deployed, and evidence on the safety and efficacy of the investigational therapeutics, are beyond WHO’s control; the IOAC urges all parties to support increasing access to these medical countermeasures. 1 GSM is WHO’s Enterprise Resource Planning System. It is a highly robust IT system that gathers, collates, and produces data. For WHO, it means bringing together disparate work flows, procedures and systems into one common system across the Organization. 2 http://apps.who.int/iris/bitstream/handle/10665/276544/WER9349.pdf?ua=1, accessed 12 December 2018. 3 MEURI protocol, http://www.who.int/emergencies/ebola/MEURI-Ebola.pdf, accessed 10 December 2018. Annex EB144/8 5 14. Findings from the country visit to Uganda indicated that regulatory approval of the protocols for investigational vaccination and treatments is subject to close consultation with the national authorities, and compliance with national registrations. The IOAC recommends that WHO should leverage experiences from the Democratic Republic of the Congo and Uganda to fast track approvals for the administration of investigational vaccines and therapeutics and their deployment. WHO should enhance mentorship, training and supervision to ensure capacity to make this happen. Security and staff protection 15. The Ebola outbreak in North Kivu is occurring amidst protracted armed conflict and deep insecurity in the affected areas. Security is a critical part of the Ebola response, enabling WHO to carry out daily operations at the epicentre of the outbreak. The IOAC recognizes that WHO Senior management approached the UN Department of Peacekeeping Operations (DPKO)1 and established unprecedented collaboration with the United Nations Mission in the Democratic Republic of Congo (MONUSCO).2 The Director-General of WHO took the field trip to the outbreak epicentre in the Democratic Republic of the Congo on several occasions and, in November 2018, the Director-General provided a full briefing jointly with the Under Secretary-General for Peacekeeping to the UN Chief Executives Board.3 The IOAC congratulates the Director-General on his strong commitment and personal endeavour to ensure the safety of his staff and the partners on the ground. 16. In its previous reports, the IOAC has highlighted its concern over the lack of prioritization, capacity and capability for security. The current situation in North Kivu has acted as a catalyst to expand WHO’s current security capacity and investment. The IOAC was informed of the six international positions allocated to security across the Organization under general management for global security (four at headquarters; one at the Regional Office for Africa; one at the Regional Office for the Eastern Mediterranean), and that an additional six international positions have been established to facilitate back fill and surge support. The IOAC recognizes that WHO is part of the United Nations Security Management System (UNSMS), and that the WHO security team in North Kivu is working proactively on a daily basis with the UN Department of Safety and Security (UNDSS)4 and MONUSCO on strategic, operational and tactical security management. The IOAC welcomes WHO’s initiative to leverage other UN agencies’ field experience and tools, such as the application developed by the International Organization for Migration for tracking staff. 17. The IOAC acknowledges that there is increasing demand for WHO to operate in politically unstable and fragile contexts, as well as in conflict settings. This poses a different set of security and operational challenges, and WHO needs greater capacity to navigate through such challenges. Provision of adequate equipment, increased staff awareness, hands-on training, and full compliance with the UNSMS policies and other standard operating procedures (SOPs) are fundamental to ensuring preparedness and sustaining effective security. 18. The IOAC notes and welcomes the ongoing recruitment of a WHO Director of Security Services, whose function will be to establish a service that is fit for WHO’s needs and requirements, including the 1 DPKO, https://peacekeeping.un.org/en/department-of-peacekeeping-operations, accessed 10 December 2018. 2 MONUSCO, United Nations Mission in the Democratic Republic of Congo, https://monusco.unmissions.org/en, accessed 10 December 2018. 3 UN Chief Executive Board, http://www.unsceb.org/, accessed 10 December 2018. 4 UNDSS, https://www.un.org/undss/, accessed 10 December 2018. EB144/8 Annex 6 WHO corporate strategy for security, as well as related requirements and investments. The IOAC applauds the institutional recognition that has been given to WHO’s security function in emergencies but remains concerned about whether this capacity, albeit expanded, is sufficient for its operations. The IOAC recommends that WHO develop its framework of accountability in line with the UNSMS and enhance its crisis preparedness and capacity development for security management in emergencies. The IOAC will continue to keep staffing for security under review and monitor progress. 19. The IOAC reviewed the staff protection measures that are in place and expressed general satisfaction with regard to SOPs for security evacuation, general medical evacuation, Ebola medical evacuation, and psychological support. Staff and experts deployed through WHO are covered by the existing provisions and procedures of the UNSMS. The IOAC noted that updated SOPs for general medical evacuation have been published and that SOPs for specific medical evacuation in response to infectious diseases requiring high-level biosafety containment are being established. WHO has taken important steps to ensure medical evacuation for all who are responding to the Ebola outbreak, and this will also benefit partners on the ground. 20. The IOAC was informed by WHO senior leadership that the Organization has developed procedures and measures for prevention of, and response to, sexual harassment, sexual exploitation and abuse. The IOAC will keep this area of work under close review. Partnership and coordination 21. The IOAC commends WHO for the progress made in partnership and coordination with other actors responding to emergencies. Findings from the desk review, the field visits and interviews with key partners suggest that WHO is now perceived as a more reliable and credible partner with strong technical expertise and operational capacities, and able to facilitate communications with Government during emergencies. The IOAC acknowledges that the WHE Programme has been working effectively with different technical networks, including the Global Outbreak, Alert and Response Network (GOARN),1 the Global Health Cluster2 and the Emergency Medical Teams (EMTs).3 Weekly GOARN coordination has been expanded to include other key partners and stakeholders, and it has become an important platform for epidemiological update and discussions on the response among implementing partners at HQ level. However, the IOAC observed during its visit to Uganda, that partner coordination and collaboration at the district level requires further improvement. The WHE Programme is encouraged to continue engaging and working collaboratively with partners and disseminating best practice at the field level. 22. In response to the Ebola outbreak in North Kivu, partners acknowledged that the WHE Programme is coordinating a joint response plan, facilitating communications with the Government, and providing both technical and logistical support. The IOAC noted that WHO was one of the first agencies to set up a response team on the ground, and one of the few partners that have remained to carry out the response, despite the insecurity in the area. The IOAC observed that apart from WHO, there are very 1 GOARN, http://www.who.int/ihr/alert_and_response/outbreak-network/en/, accessed 10 December 2018. 2 Global Health Cluster, https://www.who.int/health-cluster/en/, accessed 10 December 2018. 3 EMT, http://www.who.int/hac/techguidance/preparedness/emergency_medical_teams/en/, accessed 10 December 2018. Annex EB144/8 7 few other agencies with strong technical and operational capacity on the ground, and that this is posing an additional burden on WHO and limiting the Organization’s ability to transfer responsibility for some response pillars to other partners. These issues should be explored with partners as soon as possible and will certainly be an important topic for the after-action review. 23. Since the last report, six new partners have joined the Global Health Cluster, increasing membership to 55 organizations. As per the previous IOAC recommendation,1 WHO has conducted a survey to map international partner capacity and is planning a national partner capacity mapping exercise. The IOAC noted that 19 out of 27 country health clusters/sectors have dedicated Health Cluster Coordinators (HCCs) but only 12 Information Management Officers (IMOs). The IOAC acknowledges that HCC positions have been filled in nine out of ten WHE Programme Priority 1 countries (Afghanistan, Bangladesh, Democratic Republic of the Congo, Iraq, Nigeria, Somalia, South Sudan, Syria and Yemen). The IOAC advises WHO to complete the recruitment to fill the dedicated full time HCC and IMO posts at country level; improve performance management through training prior to deployment; and deliver adequate support on deployment to ensure satisfactory information management and coordination. WHE Programme Finance 24. The WHE Programme is funded from three sources: a core budget, appeals and the Contingency Fund for Emergencies. For the biennium 2018–2019, out of the total WHE Programme core budget requirement of US$ 526 million, 81% had already been funded or pledged as at November 2018. The Outbreak and crisis response and scalable operations budget segment has a funding gap of only 17% of the total estimated requirement of US$ 1 billion. The IOAC was informed that the CFE had attracted seven new donors in 2018 and US$ 40 million in contributions is expected for the year. These figures confirm that WHO’s performance in the field continues to build donor trust. 25. The IOAC congratulates WHO that resource mobilization capacity has been strengthened in the WHE Programme priority countries and that the Programme has established multi-year partnerships with the existing major donors while reaching out to emerging donors. The IOAC welcomes WHO’s investment case and encourages WHO to continue donor engagement and to tailor fundraising strategies to specific donor and funding requirements. The IOAC also notes that emergencies require specialized expertise in resource mobilization and understanding of the different modalities for distinct funding streams. 26. The donor response to the Ebola outbreak in North Kivu has proved that the WHE Programme is increasingly gaining donor confidence. The IOAC was informed that there was an extremely positive donor response to the joint strategic response plan2 for the Ebola outbreak in the Democratic Republic of the Congo province of Equateur, which exceeded the initial total funding request of US $44 million. In collaboration with the Ministry of Health and partners, WHO has finalized a revised national plan3 1 See document A71/5, paragraph 36, http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_5-en.pdf, accessed 12 December 2018. 2 https://www.who.int/emergencies/crises/cod/DRC-ebola-disease-outbreak-response-plan-28May2018- ENfinal.pdf?ua=1&ua=1, accessed 14 December 2018. 3 http://www.who.int/emergencies/crises/cod/DRC-revised-plan-19october2018-en.pdf?ua=1, accessed 14 December 2018. EB144/8 Annex 8 with the total request of US$ 61.3 million for November 2018–January 2019; US$ 48.1 million are already in the pipeline. However, the donor response to the preparedness plans for the Democratic Republic of the Congo and neighbouring countries has been slow. This reflects the difficulty of raising funding for preparedness activities and the IOAC urges Member States and donors to consider the importance of preparedness in responding to, and containing, future outbreaks. 27. During the field visits to Uganda, the IOAC took note of donors’ satisfaction with the “one plan, one budget” approach to the Ebola readiness preparedness plan1 led by the WHE Programme and coordinated by the WCO. Partners recognized WHO’s systematic and coordinated support for resource mobilization. The IOAC acknowledges that joint planning is an important part of the emergency response and encourages the WHE Programme to expand this to other crises. Human resource planning, recruitment, capacity development and retention of talent 28. As of October 2018, 1583 positions (956 existing staff and 627 vacant positions) are planned for the WHE Programme, with a distribution of 47% in WCOs, 31% across the six ROs and 22% at HQ. The staffing plan has been stabilized and its distribution across the Organization is aligned with the IOAC’s previous recommendation.2 The IOAC is pleased to see that an additional 205 positions have been filled since October 2017, of which 127 are allocated to the WCOs (62%) and 73 to the six ROs (36%), compared to five at HQ (2%). 29. While recognizing the progress in staffing at country level, the IOAC notes that 47% of the planned WCO positions are still vacant. Funding shortages, lack of a pool of talent and slow recruitment processes in non-emergency contexts are identified as reasons. The IOAC recommends accelerating the recruitment process at the country level, so that the staffing capacity is brought up to 75% of the total planned positions. Such acceleration should prevent the excessive surge capacity dependency on the ROs and HQ and ensure the sustainability of operations. 30. The IOAC reiterates the importance of strengthening WCO capacity and welcomes the functional review exercises. The IOAC recommends that WHE Programme priority country classification and the country business model should be used as a benchmark in defining the WCOs’ structure. A considerable degree of flexibility should be allowed in establishing WCO staffing, which should meet country- specific needs and take account of the availability of skilled national experts. 31. A total of 123 WHO staff members were deployed to support the response to the Ebola outbreak in Equateur province in May 2018. The IOAC noted that most of those staff members were redeployed to North Kivu in August 2018 owing to limited human resources capacity, in particular to fill leadership roles in critical functions for multiple major events. The WHE Programme Staff members who have the necessary skills to manage emergencies are overstretched due to the multiple crises and prolonged deployment periods. The IOAC cautions that this practice is unsustainable in the long term and that it may jeopardize the quality of the response. WHO is urged to strengthen technical expertise across the Organization and develop a policy for surge capacity to enable, authorize and incentivize the release of high-performing senior and mid-level staff for the IMS when there is a priority 1 https://afro.who.int/sites/default/files/2018-07/WHO%20Regional%20Strategic%20EVD%20Operational %20Readiness%20.pdf, accessed 11 December 2018. 2 See document EB142/8, paragraph 28. Annex EB144/8 9 emergency, especially as regards health operations leads, senior epidemiologists and infectious disease specialists. 32. The IOAC welcomes the WHE Programme’s efforts to improve learning and capacity development for WHO’s health emergency workforce and surge capacity. A new IMS leadership training programme has been launched to identify and train staff with demonstrated or potential leadership abilities. It was piloted in the African Region in September 2018 with 51 participants, of whom 25% were recommended for leadership training so that they could perform key leadership roles under the IMS. The IOAC recommends that the WHE Programme’s best practices should be leveraged across the Organization, especially for WHO representatives, and complement corporate programmes and initiatives in staff development and learning, human resources and performance management. Emergency business processes 33. The IOAC recognized that emergency business processes have been successfully implemented and have enhanced WHO’s overall performance in the Ebola response by allowing the rapid deployment of staff and provision of supplies based on a no-regrets approach. The CFE was released 2 days after the declaration of the outbreak. Over 300 international staff have been deployed to the field for operational and technical support and US$ 4.5 million worth of supplies have been delivered to the Democratic Republic of the Congo 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. Specialized products were also successfully procured and transported, including vaccines and therapeutic agents requiring specialized logistics and supply chain management, such as refrigeration. 34. The IOAC notes that bulk supplies for health emergencies have technical specifications and require distinctive operational procedures. The IOAC is pleased to see that the WHE Programme is developing disease-specific commodity packages based on disease-specific clinical guidance for supply- chain management. The IOAC was informed that a benchmarking exercise had been conducted and that the WHE Programme is currently in discussion with the World Food Programme (WFP)1 regarding the development of operational service-level agreements to capitalize on the strength of WFP’s logistical capability. The IOAC congratulates WHO on initiating development of an Organization-wide exercise to review supply and procurement management, consolidate different components of supply-chain processes that are currently managed by different parts of the Organization, and identify areas where they can use the capacity of partners. Programmatic areas: IHR core capacities and health systems 35. The IOAC noted that as at October 2018, 86 countries had undertaken a Joint External Evaluation (JEE), and 86 simulation exercises had been conducted. Over the last two years, 38 National Action Plans (NAPs) for Health Security have been completed, including in 19 countries from the African region. The IOAC acknowledged WHO’s intense efforts throughout the process but expressed concerns regarding the proportion of countries that have developed NAPs, the time frame post-JEE for development of the NAP, and assessment of the impact of the plan on the national health system and emergency preparedness. The IOAC recommends that WHO streamline the process, and support 1 http://www1.wfp.org/, accessed 11 December 2018. EB144/8 Annex 10 countries in developing simplified and impact-oriented NAPs which prioritize short-term goals with timelines for implementation. While prioritizing short-term planning, an investment strategy with medium- and long-terms goals should also be defined. The IOAC reiterates that NAPs should assist countries in strengthening their health systems and ultimately enable them to manage health emergencies though increased IHR core capacities. 36. The WHE Programme informed the IOAC that 42 after-action reviews were conducted in 29 countries between January and October 2018. During the country visit to Uganda, the IOAC heard how the JEE had helped in identifying gaps and subsequently in Ebola preparedness planning when the Democratic Republic of the Congo outbreak was declared. Uganda also recognized WHO’s support in successfully controlling the Marburg outbreak in 2018 and in conducting the after-action review. However, the IOAC noted that the JEE recommendations and lessons learned from previous outbreaks are not yet fully implemented. WHO is urged to support countries in implementing corrective measures for critical areas of work identified in JEEs and after-action reviews. 37. The IOAC noted the strong linkages between the WHE Programme and other WHO Programmes in strengthening IHR core capacities and health systems, in particular in fragile, conflict-affected and vulnerable settings. The IOAC reviewed the interface between the WHE Programme and other parts of WHO working on health system strengthening and universal health coverage, the extent to which mechanisms for strengthening collaboration have been put in place, and the strategic direction and implementation plans that have been developed. The IOAC acknowledges the ongoing efforts but recommends further coordination in strategic planning and implementation. WHO is encouraged to reinforce the pool of expertise across the Organization and to allocate a core budget for supporting countries with transition activities following major events, with a view to building IHR core capacities in a more sustainable way. III. CONCLUDING REMARKS 38. The Ebola crisis in West Africa during 2013–2015 revealed the extent to which the world is vulnerable to epidemics and ill-prepared for health emergencies. WHO undertook wide-ranging reforms of its work in disease outbreaks and global health security after heavy criticism for its failure to warn the world of the dangers, and to respond effectively to the Ebola outbreak. Two subsequent Ebola outbreaks in the Democratic Republic of the Congo have afforded the WHE Programme with the opportunity to prove that WHO’s emergency reform has paid off and that WHO is repositioning itself as an operational organization for emergencies, whilst maintaining its leadership and reputation as a technical agency. The IOAC congratulates Member States, the Director-General and the senior leadership and WHO staff for having made great progress in this regard. However, the IOAC emphasises that WHO does not stand alone and cannot succeed without partners. The WHE Programme should explore with partners how best to sustain expertise critical to an Ebola response and to leverage each other’s comparative strengths. 39. The IOAC 2016–2018 judged that the WHE Programme would take several years to be fully implemented given the challenges noted, including WHO administrative systems and business processes that are not designed for responding to emergencies. However, the IOAC observed that the WHE Programme has significantly improved emergency business processes, taking innovative approaches to resolve bottlenecks and accelerate the existing system. The WHE Programme has succeeded in developing a series of policies, business rules, delegations of authority and SOPs for human resources, finance, procurement and security to support the emergency response. These have been standardized across different offices within the WHE Programme and embedded in the WHO e-manual. Though not all previous IOAC recommendations have yet been fully implemented, and while there are still areas Annex EB144/8 11 that the IOAC has flagged as needing further development, the WHE programme has made considerable progress, has gained the respect of UN and NGO partners, and has inspired greater donor confidence. 40. The IOAC 2018–2020 concludes that WHO’s emergency reform is on a successful trajectory and that the WHE Programme provides valuable lessons for the Organization’s overall transformation agenda. The IOAC recommends that WHO leverage the WHE Programme’s experience in transforming the whole Organization to meet the ambitious triple billion targets of the Thirteenth General Programme of Work. It emphasizes that implementation of the transformation agenda must support and strengthen response to emergencies as a priority, within an appropriate and flexible framework. The IOAC will closely monitor and oversee the progress of the WHE Programme, in the context of the Thirteenth General Programme of Work and the transformation agenda. Felicity Harvey (Chair), Walid Ammar, Hiroyoshi Endo, Geeta Rao Gupta, Jeremy Konyndyk, Precious Matsoso, Theresa Tam = = =