Toward a Common Secure Future: Four Global Commissions in the Wake of Ebola

Lawrence Gostin and colleagues offer a set of priorities for global health preparedness and response for future infectious disease threats.

• System-wide accountability is vital to effectively prevent, detect, and respond to future global health emergencies.
• Global leaders (e.g., United Nations, World Health Assembly, G7, and G20) should maintain continuous oversight of global health preparedness, and ensure effective implementation of the Ebola commissions' key recommendations, including sustainable and scalable financing.
The world is becoming increasingly vulnerable to pandemics resulting from globalization, urbanization, intense human/animal interchange, and climate change. A series of global health crises have emerged since 2000, ranging from Severe Acute Respiratory Syndrome (SARS) and its phylogenetic cousin Middle East Respiratory Syndrome (MERS), to pandemic Influenza A (H1N1), Ebola, and the ongoing Zika virus epidemic. The Ebola epidemic gave rise to four global commissions proposing a bold new agenda for global health preparedness and response for future infectious disease threats [1][2][3][4][5][6][7]. In response to critiques of WHO's performance during the Ebola crisis, the World Health Assembly (WHA) approved an Advisory Group on Reform of WHO's Work in Outbreaks and Emergencies, which reported in January 2016. The WHA also approved a Review Committee on the International Health Regulations (2005) (IHR), due to report in May [8].
The commissions were established to critically evaluate the national and global response to Ebola and to enhance preparedness to prevent, detect, and respond to future infectious disease threats. Each commission had its own membership and funding described in S1 Table, but had similar mandates to improve global health security. Given the major threat posed by infectious diseases, these panel reports should drive the agendas of the WHA and the G7 Summit in 2016, and global leaders should then maintain heightened oversight of global health preparedness going forward.
Pandemics pose a significant risk to security, economic stability, and development. The CGHRF estimated annualized expected losses from pandemics at $60 billion per year-$6 trillion in the 21 st century-yet the global community has significantly underestimated and under-invested in pandemic threats. CGHRF recommended an annual incremental investment of $4.5 billion-65 cents per person-to strengthen global preparedness. This modest investment would provide a major security dividend.
This article focuses on three major reform dimensions-national health systems, global governance, and research and development-and offers a set of priorities drawing on the findings of all four commissions. S1 and S2 Tables compare the four commissions' reports along these dimensions. To make the world safer, we need robust health systems; an empowered WHO, with strengthened response capacities; a well-funded and planned research and development strategy; and system-wide accountability.

National Health Systems
Robust and sustainable health systems are an indispensable prerequisite for health security. The IHR-the governing framework for managing infectious disease outbreaks-requires 196 States Parties to develop and maintain core health system capacities to detect, assess, report, and respond to potential public health emergencies of international concern (PHEIC) [9]. Core capacities include a health workforce, laboratories, data systems, and risk communication to identify and contain threats before they cross national borders (Fig 1). The initial target date for establishing these capacities was June 2012 [10].
WHO has traditionally measured national health capacities by allowing states to conduct annual self-assessments. Most states, however, missed the initial 2012 reporting requirement for meeting IHR core capacities and, in 2014, WHO extended the deadline to 2016 for all 81 states that requested extensions. Of the 193 states required to report, only 64 states reported meeting core capacities, representing a compliance rate of just over 30%, while 48 failed to even respond [10]. This low level of compliance for meeting minimum core capacity standards may be an overestimate because self-assessments are unreliable without independent validation. Table 1 highlights the commissions' recommendations to develop and assess core capacities. The WHO took an important step in February 2016, developing a Joint External Evaluation Tool to evaluate IHR capacities every 5 years, with national and international subject experts reviewing self-reported data, followed by a country visit and in-depth discussions. Each country's assessment will be made public, with a color-coding scheme to delineate implementation levels for each capacity [11]. Until governments achieve a high degree of compliance with IHR obligations, however, WHO should plan more frequent external assessments, rather than  waiting 5 years between assessments. Participation of stakeholders in the community should also be a critical component of assessments.
A major weakness of WHO's new mechanism for monitoring the core capacities of states is that it is voluntary, reflecting state sovereignty concerns. Ensuring compliance with IHR obligations, even with better reporting, requires creative incentives, technical and financial support, and transparency. Table 2 highlights the commissions' recommendations on financing and incentives towards ensuring countries report their core capacities and meet their minimum IHR obligations. The International Monetary Fund (IMF) could encourage countries to participate in ongoing evaluations by incorporating pandemic preparedness into its evaluation of macroeconomic stability [4]. IMF assessments offer a powerful inducement given their influence over countries' access to capital. Similarly, the World Bank's Pandemic Emergency Facility-along with regional development banks-could condition disbursements based on governments meeting IHR obligations.
Political leaders are more likely to cooperate if they view external evaluations as a pathway to funding and technical support. Consequently, WHO should not simply give countries a pass/fail grade; rather, it should constructively partner with governments. Core capacity financing, however, requires the international community to close an investment gap of $3.4 billion per year [4]. WHO and the World Bank should develop a financial plan, with targets for national and international contributions. Additional financing mechanisms could be modeled on the Global Fund, with the World Bank and WHO hosting periodic donor investment and replenishment conferences.
The Global Health Security Agenda (GHSA), a partnership initiated by the United States encompassing nearly 50 countries, which was set up to prevent, detect, and respond to future infectious disease outbreaks, could offer a model for strengthening health systems [12]. GHSA, with >$1 billion in funding, has developed "Action Packages," where priority technical areas are identified, with each encompassing a target and action items, along with baseline assessment, planning, and monitoring activities, and capabilities evaluated through a peer assessment process [13]. GHSA, however, formally stands outside the IHR framework, thus lacking the international legitimacy of a WHO-led process. The minimum core capacities set out by the IHR on their own are insufficient to respond to public health threats and emergencies, however, as highlighted by the commissions' recommendations in Table 3. Effective primary care and public health systems that underpin inclusive, high-quality universal health coverage (UHC) are also required to manage outbreaks and meet a broad range of health needs to ensure the right to health. Fast-spreading novel infections are diverse, demanding resilient health systems. As outbreaks stretch existing resources, resilient systems that are designed to ensure surge capacity in health emergencies are needed.
The UN Sustainable Development Goals (SDGs) expressly encompass infectious disease outbreaks and set a target for UHC by 2030 [14]. Many of the commissions' recommendations fall within the SDGs' framework as described in S2 Table. The SDGs, in supporting universal health systems, stress health equity, which is also vital because outbreaks often emerge in marginalized communities and then rapidly spread.
Achieving resilient health systems is a shared national and global responsibility. By 2017, every government should develop and publish concrete plans to achieve IHR core capacities by 2020. By the end of the following decade, all nations should achieve the SDG target of health coverage for all.

Global Governance for Health
The commissions' reports reflecting on the Ebola epidemic echoed a crucial point made by the IHR Review Committee on the response to the H1N1 pandemic in its 2011 report-"the world is ill-prepared for a severe pandemic or for any similarly global, sustained and threatening public health emergency" [15]. At an international level, the commissions' reports focused on reforms for WHO and the UN System, but also discussed the role of the World Bank and World Trade Organization (WTO) ( Table 4).

World Health Organization
If national health systems are the foundation for global health security, WHO is at the apex [16]. Yet WHO faces a crisis of confidence, with major critiques of its performance during Ebola. The Organization had previously cut nearly two-thirds of its emergency response unit; delayed fourand-a-half months before declaring a PHEIC; and lacked the governance needed to coordinate multiple stakeholders, including its regional and country offices [17]. As featured in the recommendations in Table 5, the commissions called for emergency preparedness and response to become "a core part of WHO's mandate, positioning itself as an operational organization" [8].
The commissions also unanimously recommended that WHO create a Centre for Emergency Preparedness and Response (CEPR), integrating and strengthening all its preparedness, response, No recommendation. WHO must develop an organizational culture for emergency preparedness and response. (Rec. 10) Integrating Regional & Sub-Regional Networks WHO should strengthen its linkages with regional and sub-regional networks to enhance mutual support and trust, to promote sharing of information and laboratory resources, and facilitate joint outbreak investigations among neighboring countries. WHO should support the efforts of regional and sub-regional organizations to develop and strengthen their standing capacities to monitor, prevent, and respond to health crises. (Rec. 5) No recommendation. commissions' recommendations regarding WHO's ongoing reforms. As WHO's emergency operational capacities are upgraded, states must not cut funding for its other core activities, including noncommunicable diseases, injuries, and mental health-the Harvard/LSHTM panel recommended "its functions should be far more circumscribed" [3]. In March 2016, the Secretariat launched WHO's Health Emergencies Programme to assure "cross-organizational standards and rapid decision-making in health emergency operations" [7]. The Programme's development was influenced by the Advisory Group on Reform of WHO's Work in Outbreaks and Emergencies, whose recommendations are highlighted in Table 7. Whether the Programme meets the panels' standards for a quasi-independent Centre of high quality and accountability remains to be determined. Currently, the Programme has no sustained funding or independent governance. However, the Director-General is establishing an Independent Oversight and Advisory Committee to monitor and oversee the Programme's performance.

The United Nations System
When a health crisis escalates to a humanitarian disaster, even a well-resourced WHO will be unable to galvanize political will and coordinate a broader response, requiring operational control to shift to the United Nations. Table 8 highlights the commissions' recommendations on the UN's role and responsibilities during a health crisis. WHO should advise the UN Emergency Relief Coordinator to make this determination based on criteria for a Level 3 emergency (the highest level), including the epidemic's scale, economic toll, and political destabilization [18]. The UN Inter-Agency Standing Committee, "the primary mechanism for inter-agency coordination of humanitarian assistance," [19] would establish procedures for UN inter-agency coordination [6]. A UN Security Council resolution would elevate a crisis to the top tier of the global agenda. As binding international law, a Council resolution would be more effective in mobilizing resources, sustaining political will, and securing state compliance with WHO recommendations. The Secretary-General could also appoint a special envoy or establish a mission to implement Security Council directives [6].
It is also important to ensure ongoing UN engagement during inter-crisis periods. The UN High-Level Panel recommended the General Assembly form a Council on Global Health Crises, while the Harvard/LSHTM panel proposed a standing Global Health Committee within the Security Council. Creating a standing presence in a UN organ and, where necessary, declaring a Level 3 Emergency would raise the public and political profile of global health security in ways WHO has been unable to achieve.

Research and Development (R&D)
The Ebola and Zika epidemics revealed systemic deficiencies in R&D for diagnostic tests, vaccines, and therapies. The paucity of medical technologies stem primarily from low commercial priority, limited funding, and practical challenges of conducting human trials for episodic infections. Yet medical countermeasures are vital to contain outbreaks and minimize their impact.
As highlighted by the recommendations in Table 9, WHO has a central role in establishing the normative framework for R&D including priority setting, accelerating trial design and administration, regulatory pathways, and equitable access. The Organization spearheaded an international effort for an Ebola vaccine. More recently, WHO identified eight pathogens as research priorities, but at a high level of generality [20]. In March 2016, WHO published more granular priorities for Zika, including vector control [21]. Vaccine platform technologies may be able to accelerate the development of a vaccine for the Zika virus, as well as other pathogens. Yet, even with expedited vaccine development, inadequate access to existing vaccines still persists. For example, Yellow Fever vaccine stockpiles during a recent outbreak have been exhausted. CGHRF recommended an independent Pandemic Product Development Committee to mobilize resources, coordinate public/private actors, and create a strategic R&D plan.
CGHRF, joined by other panels, urged $1 billion incremental funding per year from combined governmental and private sources to jumpstart research innovations (Table 10). Beyond

System-wide Accountability
Implementing the commissions' bold agenda requires system-wide accountability. Figs 2 and 3 demonstrate the commissions' suggested accountability frameworks during both inter-crisis and global health emergency periods. All frameworks would require continual communication and inter-agency collaboration, as well as partnerships with multiple stakeholders. The UN High-Level Panel called for a Summit on Global Public Health Crises in 2018 to assess implementation. The Harvard/LSHTM Panel went further, proposing a UN Accountability Commission to oversee the full range of actors [3].
The commissions proposed greater WHO accountability, including independent oversight of a future CEPR. To conform with WHO's Constitution, accountability would reside in the Executive Board to which the new Centre would report, with full transparency. The Independent Oversight and Advisory Committee of the newly established WHO Health Emergencies Programme will report to the Executive Board, but ultimate authority rests with the Director-General for WHO's work in health emergencies.
Holding sovereign governments accountable poses the greatest challenge. States have sometimes failed to promptly report potential PHEICs or share crucial health information. Many states have erected unnecessary travel and trade restrictions or infringed on human rights. The commissions unanimously recommended that the Director-General publicly name governments that fail to act as responsible global citizens [22]. Beyond transparency, it may be possible to coax states' compliance with their IHR obligations through skilled diplomacy and incentives.

Political Leadership
The commissions' proposals are ambitious, with action needed everywhere from civil society and research laboratories to Geneva and national capitals. Political attention to global health security can no longer be episodic, limited to when an epidemic strikes. Political leadership must be sustained by standing agendas on health security at the WHA, G7, G20, and Security Council, with the United Nations overseeing crucial reforms. The commissions have defined a path forward. It would be a reckless disregard for human life and security to resist vital reforms.
Supporting Information S1