The Obama Administration has requested $6.18 billion in emergency funding to fight and contain Ebola. The ask is now in the hands of Congress, but given that Ebola incidence seems to be on the decline in many (not all) districts in West Africa, some leaders are losing steam on the response. But sustained support to fight the current Ebola outbreak is still essential. Moving forward, it’s crucial to ensure the efforts financed address the current Ebola crisis and contribute to public health preparedness in general. 

So what have we learned so far that needs to be reflected in next steps?  

Lesson 1: Activate public health and humanitarian responses together

If a large disease outbreak were to take root in the United States, we would expect to see the Federal Emergency Management Agency on the ground alongside the Centers for Disease Control. In West Africa, the humanitarian disaster response to Ebola only came after the initial, epidemiology-focused public health response of contact tracing.  The International Health Regulations do not address this issue directly, instead implicitly assuming local health systems are enough to respond to a large-scale outbreak. In reality, country health systems—including those in the United States—may lack the resources and planning to advance a timely humanitarian response.  The Administration’s request seems to acknowledge this shortcoming, budgeting considerable resources for domestic state and hospital preparedness; such preparedness should also be supported in low-income countries by the emergency funding request.  However, more could be done to prepare the humanitarian response.

Lesson 2: Institute callable capital (and personnel) for outbreak response

Ebola fundraising only began well after the outbreak had advanced. As a result, funding was insufficient and arrived late. This is not a new problem; while the World Health Organization (WHO) has a contingency fund for outbreak response, the fund is structured such that money sits around unused and few donors are motivated to contribute (see here). A more effective outbreak contingency fund would work more like callable capital at the multilateral development banks.  With callable capital, member countries are not required to provide funds unless and until that funding is needed, and there are clear triggers for automatic disbursement in case of need. A similar (binding) mechanism could be considered domestically, in lieu of emergency funding requests.  The emergency funding request does include an Ebola-specific contingency of US$ 1 billion, but could such a contingency fund be made more generic with clear rules that would trigger disbursement in the case of public health emergencies? A similar approach for an advanced commitment of qualified personnel through an “infectious disease treaty” (as suggested by my colleague Charles Kenny) or a “medical NATO” could guarantee a strong, WHO-coordinated response to an outbreak of global importance anywhere.

Lesson 3: Build WHO leadership

WHO leadership was slow to facilitate a response early in the outbreak, when containment of the disease was most important, but the role of the WHO remains critical in the midst of outbreaks that cross borders. The agency is in a unique position to initiate and coordinate disease-incidence tracking, sample sharing, standard setting, lab quality assurance, and epidemiological and health-system responses.  The current US budget request includes a contribution to the WHO via the Department of State to sustain the Ebola response, but it is limited in scope and does little to ensure that the capacity of WHO is bolstered and built for the long term.

The WHO has some key reforms underway, but governance and financing reforms should go even further. That process could start with more transparent, competitive hiring for leadership positions (see here). WHO’s constituent countries should also fund the organization more and differently, to ensure its core functions in outbreak monitoring and response are adequately funded, staffed on a permanent basis, and reach the highest standard of technical excellence.  

Lesson 4: Invest in public health preparedness

Public health operations such as laboratory services, disease surveillance, and maintenance of vital statistics (including cause-of-death data) are underfinanced in most countries and states. In low-income countries, investing in such services may not be cost-effective or affordable given the limited budgets and competing demands from high disease burdens. Public health preparedness therefore requires greater global funding for these activities; global funding is appropriate because controlling infectious disease is a global public good. Stronger support for health systems would also mitigate the risks of global, cross-border threats such as antibiotic resistance and drug-resistant tuberculosis. The extent to which the US emergency funding request would invest in global health preparedness is unclear.

Lesson 5: Channel private-sector help

Many private companies based in or with interests in West Africa were anxious to contribute to the Ebola response. However, it was never clear how they might contribute beyond cash donations to Médecins Sans Frontières or the CDC Foundation. Certainly cash may be best, but companies also have products, supply chains, political influence, and other resources that might be effectively brought to bear on an outbreak response. Further, a $6.18 billion funding request begs the question of what services and products will be financed and procured. Clearer sources of information and channels for the private sector will help the current and future responses.

Ultimately, the emergency funding request could better respond to what we’ve learned over the past months, and could thereby contribute to funding implementation of the many plans and memos set out in the “action packages” described in the Global Health Security Agenda, established by the Administration. Greater clarity on how the proposed emergency funding tracks to that existing agenda is essential.