Need for a Global Health Risk Framework
• Global architecture to reduce risk and mitigate next
global health crisis
• Before the outbreak occurs, we need to identify
leaders and roles, resources, appropriate times for
responding.
• Successful containment of future outbreaks requires
timeliness.
• Coordinated response informed by good planning and
evidence, not fear or politics.
• Responders need to move as one to avoid mistrust,
stigma, or miseducation of communities.
• Need to learn now, before memories fade.
U.S. National Academy of Sciences Charter (1863)
“The academy shall, whenever called upon by any department of the
government, investigate, examine… and report upon any subject of science.”
The New York Times describes the IOM as “the most esteemed and
authoritative adviser on issues of health and medicine, and its reports can
transform medical thinking around the world.”
Global Health Risk Framework Initiative
What?
• A plan for a global architecture for preparedness and response mitigating
the threat of epidemic infectious diseases
How?
• Fall 2014: A concerned conversation between Jim Kim, World Bank, and
Victor Dzau about the Ebola outbreak;
• Support from Judith Rodin ( Rockefeller), and initial planning with World
Bank, WHO, Rockefeller
• December 2014: “Getting to Zero Ebola Cases in West Africa: A
Convening of Leaders” chaired by Margaret Chan
• March 2015: Planning meeting for Global Health Risk Framework
Support
• Paul Allen Foundation, Ford Foundation, Gates Foundation, Ming Wai Lau,
Moore Foundation, Rockefeller Foundation, USAID, Wellcome Trust
Architecture of Global Health Risk
Framework Initiative
Commission Roster
Peter Sands, MPA (Chair)
(Former) Standard Chartered PLC
Harvard Kennedy School
Gabriel Leung, MD, MPH
University of Hong Kong
Oyewale Tomori, DVM, PhD (Vice-Chair)
Nigeria Academy of Sciences
Francis Omaswa, MBBCh, MMed, FRCS, FCS
African Center for Global Health and Social
Transformation
Ximena Aguilera, MD
Universidad del Desarrollo, Chile
Melissa Parker, DPhil
London School of Hygiene & Tropical Medicine
Irene Akua Agyepong, DrPh, MBChB, FGCPS
Ghana Health Service
K. Sujatha Rao, MA, MPA
(Former) Ministry of Health & Family Welfare of India
Yvette Chesson-Wureh, JD
The University of Liberia
Daniel Ryan, MA
Swiss Re
Paul Farmer, MD, PhD
Harvard Medical School
Partners in Health
Jeanette Vega, MD, MPH, PhD
Chilean National Health Fund
Maria Freire, PhD
Foundation for the National Institutes of Health
Julio Frenk, MD, MPH, PhD
University of Miami
Lawrence Gostin, JD
Georgetown University
O'Neill Institute on National and Global Law
Suwit Wibulpolprasert, MD
Ministry of Public Health, Thailand
Tadataka Yamada, MD
Frazier Life Sciences
International Oversight Group Members
Victor Dzau (Chair), President, National Academy of Medicine
Judith Rodin (Vice-Chair), President, The Rockefeller Foundation
Fazle Hasan Abed, Founder of BRAC and Chairman of BRAC Bank Limited
Arnaud Bernaert, Senior Director, Head of Global Health and Healthcare Industries,
World Economic Forum
Chris Elias, President of the Global Development Program, Bill & Melinda Gates
Foundation
Jeremy Farrar, President, Wellcome Trust
Shigeru Omi, President, Japan Community Healthcare Organization
Paul Polman, CEO, Unilever
Mirta Roses, Former Director-General Pan American Health Organization
Shen Xiaoming, Professor of Pediatrics, Xin Hua Hospital and Shanghai Children’s
Medical Center, Shanghai Jiao Tong University School of Medicine
Tan Chorh Chuan, President, National University of Singapore
Miriam Were, Chancellor, Moi University
Architecture of Global Health Risk
Framework Initiative
Timeline
July – Commission Meeting #1
Aug-Sept – Four Workshops
•
August 5-7 – Resilient Health Systems (Ghana)
•
August 19-21– R&D of Medical Products (Hong Kong)
•
August 27-28 – Pandemic Financing (Washington, D.C.)
•
September 1-2 – Governance for Global Health (London)
Sept-Dec – Consultations
•
September 25 – US federal government
•
October 9 – International and national representatives
•
November 12 – Jim Yong Kim, President, World Bank
•
November 20 – Margaret Chan, Director-General, WHO
•
December 16 – Japanese government leadership & G7 planning
October – Commission Meeting #2
November – Commission Meeting #3
January 2016 – Report release
Four Key Features Characterized the Report
Independence.
• The remit, membership, and processes of the Commission were designed
to ensure independence from individual governments, international
agencies, and other stakeholders.
Forward-looking focus.
• Devised recommendations for the future, drawing on lessons not just from
Ebola, but from previous outbreaks, including SARS, MERS and the
H1N1 influenza and HIV/AIDS pandemics.
Comprehensiveness.
• Considered every aspect of an effective framework ranging from models
of governance at an international level to the skills and infrastructure
requirements at the local level. Assessed the implications for scientific
research and development and defined the financing requirements.
Timeliness .
• The Commission completed its work within six months to enable the
recommendations to inform policy initiatives in 2016.
Dissemination
Plan to achieve maximum impact via:
• Scholarly journals and op-eds
• Personal briefings with key leaders
• Key international events, e.g.,
–
–
–
–
–
World Economic Forum annual meeting in Davos
World Health Organization Executive Board meeting
Asia Launch in Hong Kong
Africa Launch
World Bank and International Monetary Fund spring
meetings
– G7
– Others
Outline
1.
Overview of Report Recommendations
2.
The Framework
3.
Rationale for Recommendations
4.
Financing the Framework
5.
Conclusion
2
Summary of Recommendations
Chapter 2 – The Case for Investing in Pandemic Preparedness
The G7, G20, and UN should commit to:
A.1: Implementing framework set out in this report and embodied in Rec. B.1–D.3.
A.2: Mobilizing incremental financial resources required ($4.5 billion/year).
A.3: Monitoring progress of implementation by an independent assessment in 2017 and every 3 year thereafter.
Source: Sands, Mundaca-Shah, and Dzau. In press. The neglected dimension of global security – a framework to counter infectious disease crises, a
perspective. NEJM.
3
Summary of Recommendations (Cont.)
Chapter 3 – Strengthening Public Health as the Foundation of the Health System and First Line of Defense
B.1: WHO and member states should develop an agreed-on, precise definition and benchmarks for national core capabilities,
and functioning, based on IHR and other efforts (GHSA and OIE Terrestrial Animal Health Code).
B.2: WHO should devise a regular, independent, transparent, and objective assessment mechanism to evaluate country
performance against benchmarks defined in Rec. B.1.
B.3: All countries should commit to participate in external assessment process (Rec. B.2), including publication of results.
B.4: WB, bilateral, and multilateral donors should declare that related funding will be conditional on a country’s
participation in external assessment process (Rec B.2).
B.5: IMF should include pandemic preparedness in its economic and policy assessments of individual countries, based on
outcomes of the external assessment of national core capacities.
B.6: Countries should develop plans to achieve and maintain benchmark core capacities by mid-2017 (target to achieve full
compliance with the benchmarks by 2020).
B.7: WHO should provide technical support to fill countries’ gaps in core capacities and achieve benchmark performance.
B.8: National governments should develop domestic resourcing plans to finance improvement and maintenance of core
capacities as set out in plans (Rec. B.6).
B.9: WB should convene other multilateral donors to secure financial support for lower-middle-income and low-income
countries in delivering plans (Rec. B.6).
B.10: UNSG should work with the WHO and other parts of the UN system to develop strategies for sustaining health system
capabilities and infrastructure in fragile and failed states and in war zones, to the extent possible.
Source: Sands et al., in press.
4
Summary of Recommendations (Cont.)
Chapter 4 – Strengthening the Global and Regional System for Outbreak Preparedness, Alert, and
Response
C.1: WHO should create a Center for Health Emergency Preparedness and Response (CHEPR) to lead the global effort toward
outbreak preparedness and response. This center should be governed by an independent Technical Governing Board.
C.2: WHA should agree to an appropriate increase in WHO member states’ core contributions to provide sustainable
financing for the CHEPR.
C.3: WHO should create and fund a sustainable contingency fund of $100 million through one-off contributions or
commitments proportional to assessed contributions from member states.
C.4: UN and WHO should establish clear mechanisms for coordination and escalation in health crises.
C.5: WHO should work with existing formal and informal regional and sub-regional networks to strengthen linkages and
coordination among neighboring countries.
C.6: WHO and national governments should enhance means of cooperation with nonstate actors.
C.7: WHO should establish a mechanism to generate a daily high-priority “watch list” of outbreaks with potential to become
a PHEIC. List to be communicated to NFPs daily and to the public weekly.
C.8: WHA should agree on new mechanisms for holding governments publicly accountable for performance under the IHR
and broader GHRF, including protocols for avoiding delays in data and alerts and unnecessary restrictions on trade or travel.
C.9: WB should establish the PEF as a rapidly deployable source of funds to support pandemic response.
C.10: IMF should ensure capability to provide budgetary support to governments raising alerts of outbreaks.
Source: Sands et al., in press.
5
Summary of Recommendations (Cont.)
Chapter 5 – Accelerating Research and Development to Counter the Threat of Infectious Disease
D.1: WHO should establish an independent PPDC, accountable to TGB, to galvanize acceleration of relevant R&D, define
priorities, and mobilize and allocate resources.
D.2: WHO should work with global R&D stakeholders to catalyze the commitment of $1 billion/year to maintain a portfolio
of projects coordinated by the PPDC.
D.3: PPDC should convene regulatory agencies, industry stakeholders, and research organizations to commit to:
 Adopting R&D approaches during crises that maintain consistently high scientific standards.
 Defining protocols and approaches to engage local scientists and community members in the conduct of
research.
 Agreeing on ways to expedite medical product approval, manufacture, and distribution.
Source: Sands et al., in press.
6
The Framework
1. Stronger national public health capabilities, infrastructure,
and processes built to a common standard and regularly
assessed through an objective, transparent process fully
consistent with international legal obligations under the IHR.
2.
More effective global and regional capabilities, led by a
reenergized WHO, through a dedicated Center for Health
Emergency Preparedness and Response, coordinated
effectively with the rest of the UN system, and supported by the
World Bank and IMF.
3.
An accelerated programme of R&D, deploying USD 1 billion
per year and coordinated by a dedicated committee
7
Strengthening public health as the foundation of
the health system and first line of defense
• Establish clear definition of core capacities and rigorous
external assessments to evaluate country performance
• Recognize that a fundamental part of the governments’ basic
duty is to protect its citizens against infectious disease
threats. Governments should:
– Create plans to achieve and maintain benchmark core
capacities (including resourcing plans)
– Commit to participate in external assessment process
8
Strengthening public health as the foundation of
the health system and first line of defense
• Galvanize global and regional support for national core
capacities:
– Development partners’ support should align with country plans
– World Bank’s support should be contingent on country’s
participation in external assessment
– IMF should incorporate results of these external assessment in
its economic evaluations of countries
– UNSG should take the lead to support fragile states/failed
states/warzones, working with the WHO and other parts of the
UN system
9
Strengthening the global and regional system for
outbreak preparedness, alert, and response
• Create WHO Center for Health Emergency Preparedness
and Response (CHEPR), overseen by an independent
Technical Governing Board (TGB)
• Establish clear pathways for multi-sectoral coordination with
other UN agencies, regional networks, and non-state actors
• Build mechanisms that normalize and incentivize early
reporting
10
Strengthening the global and regional system for
outbreak preparedness, alert, and response
• Create protocols to hold governments accountable for
performance under IHR
• Mobilize financial resources to enable rapid deployment of
funds for response
– CHEPR should be funded through existing resources plus an
appropriate increase (say 5%) in member states’ core
contributions
– WHO should create and fund the $100 million contingency
fund
– World Bank should establish Pandemic Emergency Finance
Facility (PEF)
– IMF should provide budgetary support to governments
raising alerts
11
Accelerating R&D to counter
the threat of infectious diseases
• Establish an independent Pandemic Product Development
Committee (PPDC) for coordinating and prioritizing R&D efforts
– Chair selected by WHO DG; WHO provides secretarial support
– Coordination mechanism needed to pinpoint existing capabilities,
identify gaps, and determine priorities for a concerted global effort to
develop, test, manufacture, and distribute the relevant medical
products in cases of emergency
• Commit and mobilize USD 1 billion per year to maintain a portfolio
of projects coordinated by the PPDC
– Portfolio should include drugs, vaccines, diagnostics, personal
protective equipment, and medical devices to build robust armory
12
Accelerating R&D to counter
the threat of infectious diseases
• Convene regulatory agencies, industry stakeholders, and
research organizations to commit to:
– High scientific standards to yield interpretable data and
strong, valid conclusions
– Open information exchange with local communities from the
outset
– Streamlining protocols to expedite medical product approval, manufacture and distribution
13
Financing the Framework
• Recognize the need to step up investment
– Scale of threat to human lives and livelihoods is significant
(economic expected loss of USD 60 billion per year)
– Commitment is needed to rectify most important gaps in
defenses
• Commit to USD 4.5 billion per year to make humanity much
safer. This includes:
– USD 3.4 billion per year to strengthen public health systems
– USD 130-155 million per year to reinforce international
preparedness and response, including WHO and contingency
funding
– USD 1 billion per year to accelerate R&D on infectious disease
threats
14
Financing the Framework
• Mobilize different sources of funds for specific
components. This includes:
– Domestic government resources for public health
upgrading, with international support where required
– WHO capabilities and contingency fund on basis of
member state assessed contributions
– World Bank PEF from innovative insurance/capital market
solutions or binding contingent commitment
– Incremental R&D funding from broad range of sources
15
Conclusion
•
Infectious disease crises pose a significant threat to global security – to
human lives and to economic well-being
•
We have neglected this threat – Ebola and other outbreaks revealed
significant shortcomings in almost every aspects of our defenses
•
The case for investing more in pandemic preparedness is compelling
–
–
•
The Commission's recommendations constitute a coherent framework for
countering the threat of infectious disease crises:
–
–
–
•
USD 4.5 billion per year would significantly reduce the risks to human lives and livelihoods
Investing in preparedness and prevention is far more cost-effective than reacting when
outbreaks occur
Reinforcing the first line of defense – public health capabilities and infrastructure at a national
level
Strengthening capabilities and coordination at a regional and global level
Accelerating R&D
We must act with urgency – and we must monitor implementation. We all have
a shared interest in making the world safer.
16
Contact information
Email Q&A questions to:
GHRFCommission@nas.edu
@GHRFCommission
#GHRF
Complete report at nam.edu/GHRF
17
Appendix
18
A. Recommendations
Commit to creating and resourcing a comprehensive
global framework
The G7, G20, and United Nations (UN), under the leadership of the UN Secretary
General, should reinforce and sustain international focus and actions to protect
human lives and livelihoods from the threat of infectious diseases by:
•
Recommendation A.1: Committing to implementing the framework set out in the
report “The Neglected Dimension of Global Security: A Framework to Counter
Infectious Disease Crises” and embodied in Recommendations B.1–D.3.
•
Recommendation A.2: Committing and mobilizing the incremental financial
resources required to implement the framework, as set out in the report “The
Neglected Dimension of Global Security: A Framework to Counter Infectious
Disease Crises,” which amount to about USD 4.5 billion per year.
•
Recommendation A.3: Monitoring progress of implementation by commissioning
an independent assessment in 2017 and every 3 years thereafter.
19
B. Recommendations
Reinforcing robust public health infrastructure and
capabilities as the first line of defense
Recommendation B.1: The World Health Organization, in collaboration with member
states, should develop an agreed-on, precise definition and benchmarks for national
core capabilities and functioning, based on, and implemented through, the
International Health Regulations and building on the experiences of other efforts,
including the Global Health Security Agenda and the World Organization for Animal
Health Terrestrial Animal Health Code by the end of 2016. Benchmarks should be
designed to provide metrics against which countries will be independently assessed
(see Recommendation B.2).
Recommendation B.2: The World Health Organization should devise a regular,
independent, transparent, and objective assessment mechanism to evaluate country
performance against the benchmarks defined in Recommendation B.1, building on
current International Health Regulations monitoring tools and Global Health Security
Agenda assessment pilots, by the end of 2016.
Recommendation B.3: By the end of 2016, all countries should commit to participate in
the external assessment process as outlined in Recommendation B.2, including
publication of results.
20
B. Recommendations continued
Recommendation B.4: The World Bank, bilateral, and
other multilateral donors should declare that funding
related to health system strengthening will be
conditional upon a country’s participation in the
external assessment process.
Recommendation B.5: The International Monetary Fund
should include pandemic preparedness in its economic
and policy assessments of individual countries, based on
outcomes of the external assessment of national core
capacities as outlined in Recommendation B.2.
21
B. Recommendations continued
Recommendation B.6: Countries should develop plans to achieve and maintain
benchmark core capacities (as defined in Recommendations B.1). These plans should
be published by mid-2017, with a target to achieve full compliance with the
benchmarks by 2020. These plans should include sustainable resourcing
components, including both financing and skills.
Recommendation B.7: The World Health Organization (WHO) should provide
technical support to countries to fill gaps in their core capacities and achieve
benchmark performance. (Technical support will be coordinated through a WHO
Center for Health Emergency Preparedness and Response; see Recommendation
C.1.)
Recommendation B.8: National governments should develop domestic resourcing
plans to finance improvement and maintenance of core capacities as set out in the
country-specific plans described in Recommendation B.6. For upper- and uppermiddle-income countries, these plans should cover all financing requirements. For
lower-middle- and low-income countries, these plans should seek to develop a
pathway to full domestic resourcing, with a clear timetable for achieving the core
capacity benchmarks.
22
B. Recommendations continued
• Recommendation B.9: The World Bank should convene other
multilateral donors (including the African Development Bank,
Asian Development Bank, New Development Bank, United
Nations Development Program, and Asian Infrastructure
Investment Bank) and development partners by mid-2017 to
secure financial support for lower-middle- and low-income
countries in delivering the plans outlined in Recommendation B.6.
• Recommendation B.10: The United Nations (UN) Secretary
General should work with the World Health Organization and
other parts of the UN system to develop strategies for sustaining
health system capabilities and infrastructure in fragile and failed
states and in warzones, to the extent possible.
23
C. Recommendations
Strengthening international coordination and capabilities is the
next most vital component of the framework.
Recommendation C.1: By the end of 2016, the World Health Organization should
create a Center for Health Emergency Preparedness and Response action at
headquarters, regional, and country office levels—to lead the global effort toward
outbreak preparedness and response. This should be governed by an independent
Technical Governing Board.
Recommendation C.2: In May 2016, the World Health Assembly should agree to an
appropriate increase in the World Health Organization member states’ core
contributions to provide sustainable financing for the Center for Health Emergency
Preparedness and Response.
Recommendation C.3: By the end of 2016, the World Health Organization should
create and fund a sustainable contingency fund of USD 100 million to support rapid
deployment of emergency response capabilities through one off contributions or
commitments proportional with assessed contributions from member states.
24
C. Recommendations continued
• Recommendation C.4: By the end of 2016, the United Nations (UN) and
the World Health Organization should establish clear mechanisms for
coordination and escalation in health crises, including those that become
or are part of broader humanitarian crises requiring mobilization of the
entire UN system.
• Recommendation C.5: By the end of 2017, the World Health Organization
should work with existing formal and informal regional and sub-regional
networks to strengthen linkages and coordination, and thus enhance
mutual support and trust, sharing of information and laboratory
resources, and joint outbreak investigations amongst neighboring
countries.
• Recommendation C.6: By the end of 2016, the World Health Organization
and national governments should enhance means of cooperation with
non-state actors, including local and international civil society
organizations, the private sector, and the media.
25
C. Recommendations continued
Recommendation C.7: By the end of 2016, the World Health Organization
(WHO) should establish a mechanism to generate a daily high-priority
“watch list” of outbreaks with potential to become a Public Health
Emergency of International Concern to normalize the process of reporting of
outbreaks by country and encourage necessary preparedness activities. The
WHO should communicate this list to national focal points on a daily basis
and provide a public summary on a weekly basis.
Recommendation C.8: By the end of 2016, the World Health Assembly
should agree on new mechanisms for holding governments publicly
accountable for performance under the International Health Regulations
and broader global health risk framework, as detailed in Recommendation
B.2, including:
• protocols for avoiding suppression or delays in data and alerts, and
• protocols for avoiding unnecessary restrictions on trade or travel.
26
C. Recommendations continued
Recommendation C.9: By the end of 2016, the World
Bank should establish the Pandemic Emergency
Financing Facility as a rapidly deployable source of funds
to support pandemic response.
Recommendation C.10: By the end of 2016, the
International Monetary Fund should ensure that it has
the demonstrable capability to provide budgetary
support to governments raising alerts of outbreaks,
perhaps through its existing Rapid Credit Facility.
27
D. Recommendations
Accelerating R&D in a coordinated manner across the whole range of relevant
medical products to strengthen scientific and technical resources against
infectious disease threats
Recommendation D.1: By the end of 2016, the World Health Organization
should establish an independent Pandemic Product Development
Committee, accountable to the Technical Governing Board, to galvanize
acceleration of relevant R&D, define priorities, and mobilize and allocate
resources.
Recommendation D.2: By the end of 2016, the World Health Organization
should work with global R&D stakeholders to catalyze the commitment of
USD 1 billion per year to maintain a portfolio of projects in drugs, vaccines,
diagnostics, personal protective equipment, and medical devices
coordinated by the Pandemic Product Development Committee.
28
D. Recommendations continued
Recommendation D.3: By the end of 2016, the Pandemic
Product Development Committee should convene regulatory
agencies, industry stakeholders, and research organizations
to:
• Commit to adopting R&D approaches during crises that
maintain consistently high scientific standards.
• Define protocols and practical approaches to engage local
scientists and community members in the conduct of research.
• Agree on ways to expedite medical product approval,
manufacture and distribution, including convergence of
regulatory processes and standards; pre-approval of clinical
trial designs; mechanisms for intellectual property
management, data sharing and product liability; and
approaches to vaccine manufacture, stockpiling, and
distribution.
29