The Ebola crisis both revealed major weaknesses and inefficiencies in global humanitarian health governance, and prompted the development of new and more efficient ways of responding to the crisis through improving how we manage humanitarian and civil protection resources together. This article is an initial attempt to draw out some lessons for the health sector. Much wider analysis will be needed to appreciate the full impact the crisis has had on other sectors and policies and to draw conclusions on the appropriateness of the current architecture of humanitarian response and preventive action.
How did Ebola in West Africa get out of control?
The Ebola outbreak in West Africa should and could have been contained before it got out of control. Under the World Health Organisation (WHO), the Global Health Cluster is meant to provide leadership and coordination among all the main humanitarian heath agencies, either as members or observers (in the case of MSF and the ICRC). At global level WHO has a Foreign Medical Team and surge capacity. There are humanitarian Global Clusters for other sectors relevant to the Ebola response, such as logistics and water, sanitation and hygiene (WASH), and OCHA is resourced for humanitarian coordination and leadership. For months none of these resources was applied, leaving MSF largely alone on the ground and pursuing a solo global advocacy campaign to increase treatment capacity.
Three main observations can be made. First, leadership and coordination, both within international health governance and international humanitarian governance, has been a concern throughout. Management of the crisis by the WHO was weak, and country-based humanitarian governance mechanisms remained low-key and did not promptly request global support. Addressing these weaknesses must be the starting-point for reviewing the global system response. Second, improved oversight of the government response is essential, for example to ensure the necessary transparency of information to enable an appropriate response and the earlier engagement of Global Health Cluster resources. Equally, the failure of humanitarian governance reflects the disconnect between the development side of the UN and its humanitarian elements, raising serious questions about whether the Resident Coordinator should be responsible for humanitarian coordination. Third, in terms of visibility and funding the Ebola outbreak has had to compete with a range of major high-profile crises, but even with limited existing resources the capacity was there to contain the outbreak and to avoid the massive loss of life, suffering and long-term costs that have resulted. Given the likely increase in the frequency and scale of such outbreaks and other health emergencies, additional resources are required for the health sector, but their effectiveness will be in doubt without improved governance.
WHO needs to ensure that staff in key posts are adequately equipped for their roles, including full awareness of resources for emergencies, like the health cluster. Provision is available for this in major health emergencies under the WHO Health in Emergencies Framework step aside clause, which can be applied to remove country representatives who are not equipped to provide the appropriate leadership in a humanitarian crisis.
The Health Cluster should have been triggered much earlier, and certainly by the end of May, when it was clear that needs were expanding far beyond the capacity of the response. Indeed, in Guinea a health cluster had been activated four years previously, so it was simply a question of reactivating a dormant cluster and bringing in the expertise and capacity of the Global Health Cluster and its related resources. Triggering the Health Cluster could have ensured sustained presence of higher-quality leadership and a clearer division of labour. Equally, a larger, more rapid and better-coordinated deployment of Foreign Medical Teams would have helped address the main problem of lack of operational capacity on the ground. The early triggering of the Health Cluster would also have avoided the later problem of extra layers of coordination among the wide range of more peripheral actors and activities. Lastly, a timely reaction would also have facilitated attention and support to maintaining the health systems in Ebola-affected countries in order to deal with other deadly health challenges such as malaria.
There is a clear need for improved humanitarian health sector capacity through greater participation of health agencies, notably MSF, in the Global Health Cluster. MSF staff have been vital (and largely alone for much of the outbreak) in treating Ebola; however, as also seen in the Central African Republic MSF does not have the capacity to cover all treatment and other health-related needs. The operational capacity of humanitarian health agencies needs to be increased, and MSF needs to deepen its cooperation with the Global Health Cluster to address this.
Overall funding to the humanitarian health sector has been decreasing while needs across the sector are growing, which means that funding has to be targeted where it will have the greatest impact on the most urgent needs. This requires improved effectiveness in global health and humanitarian governance. The potential use of the capacity of non-traditional responders should also be evaluated. For donors to focus their global capacity-building funding to make the system more effective, humanitarian health agencies have to provide a common position on where the priority needs are. For example, priority sub-sectors where needs appear to exceed capacity are epidemic outbreak and secondary health care. The Global Health Cluster should be the forum to establish this common position.
Scaling up the Ebola response and synergies between civil protection and humanitarian assistance
While the integration of civil protection and humanitarian aid was well under way within the European Union (EU), the Ebola crisis greatly expanded it. This was done largely through the Ebola Task Force, housed in the European Commissions Emergency Response Coordination Centre (ERCC). Because of its scale and nature, the crisis also triggered the use of diplomatic, development, research, military and civil protection instruments. As it touched on so many sectors and involved so many response actors, the entire process needed a more coordinated European approach. With daily meetings, the Ebola Task Force ensured information-sharing and better understanding of all aspects of the response, integrating the work of actors not used to operating together.
Broadly speaking, the humanitarian response addressed the frontline issues: deployment of humanitarian experts to liaise with partners and local authorities; funding for surveillance, diagnosis and treatment, and for maintaining regular health services; and medical training and supplies, including Personal Protective Equipment. The European civil protection contribution has ensured that this frontline work can take place by providing health and humanitarian personnel and equipment, and by ensuring a safe and guaranteed medical evacuation system. Both elements have been crucial to the response. Key components of the civil protection role in the response have been the transport of staff and materials for teams and emergency treatment units; the provision of medical teams; a laboratory; emergency treatment units, training facilities and trainers; and the deployment of experts.
While the Commissions humanitarian aid budget is financing teams through United Nations, Red Cross and non-governmental organisation partners, a significant contribution has been made by a number of individual EU members, channelled through the EU Civil Protection Mechanism (EU CPM). In September 2014 the lack of a medical evacuation capacity for Ebola cases was identified as a major bottleneck in the deployment of European health and humanitarian workers to affected countries. By the end of October, the ERCC, working in close collaboration with the Health Security Committee, chaired by the European Commission, and with WHO, had established a medical evacuation system for all international humanitarian staff, providing round-the-clock evacuations to specialised EU hospitals.
Some lessons to learn, some mistakes to avoid
Global humanitarian health governance urgently requires improvement, especially for disease outbreaks. This was recognised at WHOs Executive Board meeting in January, which adopted a resolution that included key measures for reform, including becoming fit for purpose in its humanitarian role; the more timely declaration of appropriate response levels to humanitarian emergencies; and a more extensive global public health workforce.
The Ebola crisis has led to the creation of additional global resources through the improved integration of civil protection and humanitarian aid. These now need to be better institutionalised within global humanitarian health governance. This is already under way, for example with EU Foreign Medical Teams for global deployment. The primary failing of the Ebola response was not lack of resources, but rather persistent weaknesses in utilising existing resources. In consequence, massive additional resources were needed, depleting resources for other humanitarian crises. One useful outcome has been an improvement in the synergies between civil protection and humanitarian assistance on an EU level.
Apart from the dramatic short- and long-term consequences of the Ebola epidemic for the countries most concerned and the West African region as a whole, the development of this crisis raises concerns regarding the concrete implementation of a range of concepts much discussed in the humanitarian community, including Early Warning-Early Action, global reach and the functioning of the humanitarian architecture post the Transformative Agenda. The process leading up to the World Humanitarian Summit in 2016 should be used to learn lessons from an emergency which, although far less complex than other humanitarian crises, was not contained in time. The answer is not just more resources, but first and foremost better governance of the resources that are available including better synergies between humanitarian aid and civil protection.