May 30, 2015 Volume 385 Number 9983 p2121-2222
African health leaders: claiming the future
Agnes Binagwaho, Nigel Crisp
Improving health in Africa is a team effort that involves many people from different backgrounds. The health gains made in recent years would not have been possible without the contribution of these people, national and global political will, and the support of development partners. All too often, however, the part played by Africans themselves has been overlooked or downplayed internationally in policy making and publications.
Offline: An irreversible change in global health governance
“We should have reacted sooner”, was Angela Merkel’s conclusion in her address to the World Health Assembly last week. She was speaking about Ebola, and she gave a sharp and public rebuke to WHO for its diffident performance. WHO’s decentralised structure can be a powerful advantage, she said, but it “can also impede decision-making and hinder good functioning”. Still, despite its weaknesses, “WHO is the only international organisation that enjoys universal political legitimacy on global health matters.” It should be supported. Her assessment was backed by the Ebola Interim Assessment Panel, chaired by Barbara Stocking and whose first report was debated by WHO’s member states the next day. Stocking and her team, which included, among others, Ilona Kickbusch and Julio Frenk, listed their concerns with compelling clarity. They expressed surprise that it took WHO so long to recognise what it would take to bring Ebola transmission under control. Why did repeated early warnings from May to July, 2014, fail to trigger the declaration of a Public Health Emergency of International Concern before Aug 8, 2014, the date when an emergency was finally announced? Why was WHO unable “to engage in a high-level media response with greater command over the narrative”? Why did WHO fail to seek appropriate support from other UN agencies and humanitarian organisations? Why did WHO fail to ensure it had the operational capacity and culture to manage a public health emergency response? Donors were not spared: WHO “suffers from a lack of political and financial commitment by its Member States”. The Panel commented that “this [is] a defining moment for the work of WHO…’Business as usual’ or ‘more of the same’ is not an option.” Stocking concluded that, “Now is the historic political moment for world leaders to give WHO new relevance and empower it to lead in global health.”
Understandably, the Panel preferred to place responsibility on structures, not individuals. This is entirely correct. But structures are made up of individuals, and it is individuals who make decisions. There needs to be some serious soul-searching within the agency about who did what, when, and why it went wrong. The Lancet has felt resistance to these questions, in sometimes acutely hostile terms from WHO staff members. If WHO diagnoses the international response to Ebola as a collective failure and not as a failure of its own processes, procedures, and people, it risks sustaining the conditions that have led to this public health catastrophe for millions of west Africans. For example, it is surreal for WHO to say, as it did last week, that it has now heard what the world expects from the agency. Does this statement mean it was only when Ebola swept across west Africa that WHO woke up to an understanding of its global role? When WHO says that it will strengthen its command and control systems, does this statement mean that after six decades of experience in responding to health crises it needed Ebola to make the agency realise the importance of leadership? And can anyone take the statement that Ebola has accelerated reforms to the organisation seriously when the recent “WHO reform” programme is widely judged (internally and externally) to have delivered few tangible benefits to the agency’s work?
Debates about Ebola and WHO’s response (and future) certainly overwhelmed discussions in Geneva last week. But the most exciting moment was not in the Assembly Hall or Committees. Instead, it was in a small room in the Palais des Nations, and after hours too. For the first time in the history of WHO and its Assembly, a civil-society led forum was held to strengthen political accountability for global health—specifically, for women’s and children’s health. The White Ribbon Alliance, together with the Governments of Bangladesh and Sweden, convened the first Global Dialogue between Citizens and Governments. It was an historic moment. It built on National Citizen’s Hearings held in over 20 countries. Examples from Indonesia and Tanzania were presented with informed passion. Indonesian and Namibian Ministers of Health spoke. This Global Dialogue signalled the beginning of a very different World Health Assembly. What took place last week was an irreversible change in the governance of global health—one in which civil society assumed a legitimate place in shaping the future of health. While WHO reflected (sometimes painfully) on its role and purpose, civil society found its voice. Mark this moment.