New England Journal of Medicine
September 10, 2015 Vol. 373 No. 11
http://www.nejm.org/toc/nejm/medical-journal
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Perspective
Creating a Global Health Risk Framework
Victor J. Dzau, M.D., and Judith Rodin, Ph.D.
N Engl J Med 2015; 373:991-993 September 10, 2015 DOI: 10.1056/NEJMp1509136
The Ebola outbreak in West Africa tragically illustrated the shortcomings of the global health system. Dysfunctional governance structures — within and among institutions and sectors — hindered response efforts. Financial and human resources were slow to arrive and insufficient,1 as they often are during humanitarian crises. Surveillance and other information systems were not up to the task. Health care personnel risked their lives to provide care, and many died. Local culture was not respected, and mistrust of the health system was rampant.2 Private industry had little incentive to proactively develop lifesaving products, and when it nevertheless did so, regulatory barriers and poor coordination hindered testing and deployment.3 The list goes on. As a result, the Ebola outbreak has had catastrophic health, economic, and social effects on Guinea, Liberia, Sierra Leone, and beyond.
Clearly, a unifying framework for managing global public health events is needed. Although previous globally significant outbreaks, such as those of the human immunodeficiency virus, influenza, and the severe acute respiratory syndrome (SARS), highlighted many of these weaknesses, the political will needed to reform the global public health framework has failed. As a result, countless lives have been lost and billions of dollars in economic damage has been incurred. The situation urgently needs to be fixed, and that requires leadership from the highest levels. We can’t allow another epidemiologic crisis to become a full-fledged catastrophe. An independent, multinational Commission on a Global Health Risk Framework for the Future has been established to recommend a more effective global architecture for mitigating the threat of epidemic infectious diseases.4 The U.S. National Academy of Medicine (formerly the Institute of Medicine) is the secretariat for this commission.
The Global Health Risk Framework (GHRF) initiative will build on lessons from the current Ebola outbreak and other major outbreaks to develop a comprehensive framework for improving our response to future global public health threats. The Commission will rigorously analyze options for improving governance, finance, health system resilience, and research and development for global health security. To foster trust internationally with various levels of government, civil society, academia, and industry, the Commission intends to keep the framework from being influenced by politics or the interests of any one country or organization.
The 18 Commission members have expertise in global health governance; workforce mobilization; global financing, including reinsurance business, economics, and public–private partnerships; information management and disease surveillance; humanitarian and pandemic response; and research, development, acquisition, and distribution. Because preparing for and responding to outbreaks requires more than medical expertise, the Commission also includes lawyers, bankers, mining executives, and others. To ensure the group’s independence, the commissioners were screened for conflicts of interest, their evidence collection and analysis will be transparent, and their report will be rigorously peer reviewed.
An international oversight group will steer the initiative and determine the scope of the study, approve the Commission slate and the initiative processes, develop guidelines for the report review process, and assist with dissemination. The initiative also includes workstream planning groups that will oversee preparations for four public information-gathering workshops, involving experts to address governance for global health, financing for public health emergencies, resilient health systems, and research and development of medical products.
The governance-for-global-health workstream will begin with a review of the current responsibilities and constraints of countries, regional institutions, the World Health Organization (WHO), and other relevant United Nations (UN) agencies, as well as the International Health Regulations (IHR), and assessment of potential changes to international governance frameworks that would ensure a robust response capability regardless of the environmental contexts. Possible ways to reform or empower the WHO and the UN system to more effectively respond to public health emergencies — such as developing guidelines for roles of non–health-focused organizations, establishing mechanisms for mobilizing a global health workforce, developing strong regional networks that share information and coordinate responses, and creating national command centers — may also be considered.
The financing workstream will start with an examination of how global funding for response to pandemic threats can be set aside in advance or rapidly mobilized, where the money should come from, and how it should be spent. The workstream group will evaluate the role of the World Bank’s proposed Pandemic Emergency Financing Facility, which will coordinate international financial response to pandemics — in particular, how the facility might ensure rapid deployment and prompt remuneration of health workers and minimize transaction times on other expenses. Vital to this discussion will be the roles to be played by the private sector, especially the reinsurance industry, in pooling risk for global emergencies. The financing workshop will explore possible underwriting functions of banks, insurers, and investment houses and analyze how they could ease the financial shock of an epidemic and control the costs of response, including the cost of developing new drugs and vaccines. The financing of surveillance systems to comply with the IHR will also be considered.
In the workstream focused on resilient health systems, optimal approaches to achieving effective, resilient, and sustainable health systems in individual countries will be considered. Multiple components of health systems will be examined, including surveillance and health information systems; universal health coverage; workforce capacity; health systems infrastructure; community, regional, and global partner engagement; supply-chain coordination and management; and how these components are connected and coordinated to form a resilient health system. Other considerations include options for enhancing connections among the health sector, other sectors (such as agriculture, education, and commerce), and the community; strengthening syndromic surveillance systems to permit early reporting and response; enhancing education and training for health care workers, community leaders, and the public; and leveraging existing systems and resources to address surge needs and capabilities. These issues will be explored in the context of other efforts including the IHR, the Post-2015 Hyogo Framework for Disaster Risk Reduction, the Global Health Security Agenda, Health in All Policies initiatives, and the Sustainable Development Goals.
In the workstream for medical-product research and development, participating experts will examine issues surrounding ensuring global capacity for relevant research and development, acquisition, and dispensing of countermeasures and diagnostics. They may explore the need for a global plan to harmonize and strengthen regulatory systems, processes, and standards; models for public–private partnerships and nongovernmental organizations to support rapid research and development and complement and reinforce private-sector mechanisms; global financing models that provide incentives for research and development; frameworks for ethical and methodologic standards for product safety and efficacy; and investments in regulatory science and multiuse platforms to support rapid development and deployment.
In each workstream, expert participants will gather diverse perspectives on various policy options, which will be captured in written workshop summaries. The Commission will integrate the evidence from these workshops, synthesizing the expertise of more than 100 leaders in health and related areas. It will then develop a comprehensive set of recommendations based on the available evidence, with the ultimate aim of strengthening systems, reducing suffering, and saving lives. The Commission will also use information collected through expert consultations, literature reviews, and public input to propose a preparedness-and-response plan that will build on and be coordinated with other efforts in this area. This plan will be captured in a final report expected to be released by December 2015.
To be effective, the report will have to be positioned to encourage global health leaders to act on its recommendations. The International Oversight Group is working closely with decision makers to coordinate dissemination of the report. The plan is to feature the Commission’s work at major events of the UN, the World Health Assembly, and the G7 and G20 groups of countries, aiming for effect well beyond the health sphere. Ultimately, world leaders’ actions will determine international preparedness for future pandemics and medical disasters. This GHRF initiative should provide sound, evidence-based guidance for their decisions.
A world health crisis such as the Ebola outbreak should never happen again. If we prepare now, we can avoid devastation when the next outbreak occurs.
vaccines and global health :: ethics and policy 