A better WHO
Dr Matshidiso Moeti was elected WHO Regional Director for Africa on 1 February 2015. She has extensive experience in public health, both nationally and internationally. We reached her in Liberia by phone to talk about her experience with the Ebola outbreak in West Africa.
Q: One year into the outbreak, what in your opinion are the key lessons learnt so far? And, what are the most important ways in which WHO shifted its efforts to improve the response to the outbreak?
Dr Matshidiso Moeti: This was the first outbreak of Ebola in West Africa. What began as a typical outbreak of Ebola, did not evolve in the usual way because of the context and prevailing circumstances. The intense movement of people within and across borders facilitated rapid spread of the infection across and within the three countries.
We have learnt that we need to engage affected communities right from the start of any disease outbreak. Attention should be focussed on cultural issues, especially those relevant to transmission. In this case, it was the burial practices that were a source of transmission. In the future, we will place more focus on interventions for behaviour change as there are often complex cultural, religious, societal and sometimes political barriers that need to be overcome.
In addition to sending in the usual outbreak team, epidemiologist, data manager and laboratory specialists, it is important to send social scientists and communication specialists in the initial phase of outbreaks. Any major event public health must be analysed within its own context. We need to take into account patterns of population movement, and the way people live in the affected area.
Epidemic preparedness and resilience of the health system are essential and go hand-in-hand. Where there is a vulnerability to public health threats, the proper preparation of the country becomes a public good and therefore an international concern. The International Health Regulations are an important tool and their application goes well beyond the actions of the health sector. Therefore, the tool needs to be known and understood not only by ministries of health, but also by other sectors active in border control, security, to some extent the army, home affairs and internal affairs.
When decisions were made about closing borders between countries, these were not decisions made by the ministries of health alone, so it is important that political authorities at the highest level understand obligations and commitments that they have made when adopting the International Health Regulations. We, as WHO, need to raise awareness among political decision-makers in countries, at the very highest level.
As the outbreak quickly evolved out of control, it was difficult to follow its pace and mobilize the capacity that was needed on the ground, which included some disciplines that WHO doesn’t routinely work with such as case management. There was an urgent need to mobilize clinicians in large numbers and, as the number of cases went up suddenly, there was a need to establish treatment centres quickly.
At one point, the limiting factor was that we didn’t have enough nurses and doctors available to provide the support that was needed. In these situations, working with partners and mobilizing additional capacities that are needed is part of our role. This underlines the greater role of WHO, not only as a responder in our own capacity but also as a mobilizer.
Q: The outcome of the Executive Board Special Session (EBSS) reaffirmed WHO’s role in responding to disease outbreaks and emergencies with public health impact, but also set an agenda to strengthen WHO’s capacity to better respond in the future. What do you see as the major changes that should/will be undertaken as part of this agenda that will have the greatest impact on WHO’s future emergency response efforts?
Dr Matshidiso Moeti: Our capacity was very quickly overwhelmed by this Ebola outbreak. I think that we should, and it was recommended in the EBSS resolution, increase our own capacity. In short, that we rely not only on the availability of the limited teams that are responsible for surveillance and management and response to epidemics, but also that we have a broader resource within WHO.
There are many staff with public health training working in other programme areas, and it would be useful if these colleagues were familiar with outbreak response and management. We need to be able to quickly respond and function in a different way to our routine normative and technical support work. So we need to improve our internal capacity and we need to mobilize regional and global expertise from other institutions or individual experts who know WHO’s tools and can be deployed rapidly when the need arises.
In addition, we need to more clearly define the mechanisms for triggering the actions of other partners, perhaps within the International Health Regulations or some other decision-making mechanism. Then, we need to be clearer on how WHO mobilizes others to act. We raised the alarm during the recent Ebola outbreak in West Africa and it took some time to get partners on the ground with the type of resources that WHO does not have internally. Also, it is important that we have a readily available source of funding for the first early action, the early assessments and interventions. This is why I think it is very important to establish a contingency fund for early response.
Q: How do you envisage WHO’s future role vis-a-vis international emergency response efforts changing in view of the Ebola outbreak? Is coordination better than at the start of the outbreak?
Dr Matshidiso Moeti: Coordination in Guinea, Liberia and Sierra Leone is now better than it was at the beginning of the outbreak, partly because we have had to learn quickly from the experiences on the ground operations. WHO’s role as coordinator has been recognized and validated. The Heads of WHO offices are playing an important role in coordinating partners in all three countries and also in supporting the countries in their coordination efforts. In the field, WHO is playing the important role of team leader as well as being the coordinator of those who are working on surveillance, diagnostics and laboratory capacities, contact tracing and even case management.
The United Nations Mission for Ebola Emergency Response (UNMEER), which was established to better coordinate the efforts of all the UN agencies in view of the scale and rapidity of the outbreak, is winding down its operations very soon and it has been agreed that the key coordination role of the health sector will revert to WHO. This is an important role that WHO has played increasingly and one that is recognized by the partners.
Discussions are ongoing at the global level about what is needed and what the ideal mechanism or institution would be. I think that this depends on the context – if it is a severe or a very large scale, very complex public health emergency that requires strong multisectoral action, what is WHO’s coordination role? How would WHO work through a clearly defined mechanism for triggering the action of the other sectors in such a public health emergency?
Q: As the new Regional Director what is your vision of positioning WHO to better support Member States in improving public health in Africa?
Dr Matshidiso Moeti: The African region is well positioned. The Member States believe in the important role of WHO and recognize the value of WHO’s support to their work in public health. Because we are working in a region that is highly dependent on international support, both financial and technical, we can and we intend to improve the way we work with other partners. In a sense, we support the countries in coordinating and aligning the support of other partners.
We are working on a regional partner mechanism called “harmonization for health in Africa”. I intend to work on improving how the mechanism coordinates partners’ action in supporting countries. As countries in Africa are working so much with international partners, it is very important that they are supported to do so effectively, do so without too much fragmentation and cost in terms of time, for the ministries. Their limited capacity should be focused on effective implementation for greater impact. Facilitating countries and partners to really work together towards the aid effective principles is a very important part of how we can help countries improve public health.
In addition, because the region still has a significant burden of communicable diseases, we will focus on health security and on helping countries finish the Millennium Development Goals agenda and implementing the Sustainable Development Goals. We have an opportunity in the African region to focus on prevention, aiming to help countries avert the looming burden of noncommunicable diseases. We will also address the social determinants of health – this outbreak has shown us these are very important.
Finally, within the reform of WHO, there are many instruments to improve our performance, our effectiveness, our efficiency, and our focus on results. We have already had discussions with all our countries and I am planning to implement the recommendations. I think we can become a better performing, more effective partner to our Member States and be more focused on delivering results for the African region.