How are outbreak responses funded and coordinated?

DANIEL CARTER: Rapid and sufficient funding of outbreak responses is essential. Without this, one can have a delayed or weakened response thereby missing opportunities to respond to the outbreak as quickly and as effectively as possible. Similarly, coordination of the response is vital. This is for three main reasons. Firstly, it’s needed for coherence. In the absence of effective coordination you may, for example, have conflicting public information messages through a poorly coordinated communication campaign. And this can lead to confusion amongst the population affected by the outbreak, or even undermine their trust in the response. Secondly, it’s needed to avoid any gaps in the response, both in terms of its components but also in terms of its geographic coverage.

A gap in just one aspect of the response could undermine the entire efforts. And thirdly, it’s needed to ensure the efficiency of the response by avoiding duplication and also by facilitating information sharing, lesson learning, and adaptation of the response as it evolves over time. It’s important to consider also that the funding and coordination of outbreak responses are very closely linked. Poor coordination makes it much more difficult for donors to identify funding gaps and to respond to these quickly and effectively. Conversely, multiple funding streams can undermine the coordination of a response.

Country governments have a clear role to play in the funding of outbreak responses. However, in many situations, particularly in the poorest countries and in fragile and conflict-affected states, the amount of funds that they have available and the speed at which they can deploy them are very limited. Furthermore, there is a risk that the funds that they do provide may simply be drawn from other pressing routine needs elsewhere in the health system. In many cases, the resources that country governments provide are made in kind, for example, in the deployments of health care workers into outbreak responses. These contributions are of fundamental importance but nonetheless do usually need to be supplemented by additional external resources.

Official donors also have a very major role to play in funding outbreak responses. This includes both bilateral donors, such as USAID or the UK’s Department for International Development, as well as multilateral donors, such as the World Bank. GAVI, the vaccines alliance, supports the stockpiling and the deployment of vaccines into outbreak responses as they did, for example, in the yellow fever outbreak that affected Angola and the Democratic Republic of Congo in 2016 and ‘17. Other organisations, such as UNICEF, the Red Cross, and NGOs, such as Medecins Sans Frontieres, may mobilise their own resources and contribute these to responses, or they may receive funds from donors for their own activities.

And finally, private sector organisations may provide support, for instance, by contributing commodities to responses, or by providing logistical support.

CHIKWE IHEKWEAZU: In Nigeria, we have a federal republic. So we have responsibilities at different levels of government. At the central level, at the federal level, the responsibility of coordination lies with the Nigeria Centre for Disease Control through which most of the funding, governmental funding, for outbreak response also flows. However, we always work in collaboration with different government ministries and departments depending on what outbreak it is. This would typically be the Ministry of Agriculture, the Ministry of Environment, Water Resources, or sometimes other stakeholders such as the National Primary Health Care Development Agency responsible for immunisation in Nigeria. Whatever level we’re working at, we always have partners. Our primary partner in outbreak response in the Nigerian context is the World Health Organisation.

They have a big team that provides us technical assistance, sometimes human resources, sometimes financial resources to support our response to outbreaks. Other key partners are UNICEF. They often come in around risk communication, support vaccination efforts. Also the United States Centre for Disease Control is a key partner, especially around human resources, around epidemiology and microbiology.

DANIEL CARTER: WHO’s contingency fund for emergencies was established in 2015 to facilitate the rapid deployment of funds to respond to outbreaks and other public health emergencies. This serves to receive funding from multiple donors into a single fund, which is managed by WHO, enabling the organisation to respond immediately when a public health emergency does occur. There is then a need to mobilise additional funding beyond the initial phase of the outbreak. Country governments and WHO work together to produce a single response plan with a budget, which then allows donors to mobilise funding and to provide these through WHO and other channels.

First and foremost, country governments have a key role to play in coordinating the response to outbreaks. After all, it is the country government that has the formal mandate and the responsibility to respond to an outbreak. And within the international system, WHO has a mandate to support country governments in fulfilling this role and in overseeing and supporting the implementation of the International Health Regulations. So it is these two organisations, country governments and WHO, which have a key role to play in coordinating outbreak responses in most situations. Key instruments to enable effective coordination is the single response plan and budget, which I’ve already mentioned.

This sets out a statement of the activities required to respond to an outbreak and the resources needed and around which both delivery agencies and donors can align. The SRP therefore makes the crucial link between coordination of the response and its funding. Public health emergency operations centres, or EOCs, can be vital in enabling effective coordination of a response. These bring together key personnel and information in a structured way in order to enable timely, effective management of a public health emergency. Coordination may be structured around the various components or pillars of a response, such as epidemiology and surveillance, vaccination, communications, and infection prevention and control. This can support effective management of the response within each of these domains.

However, it is essential that there is also a mechanism for coordination to take place between and across all of these domains in order to prevent the response from becoming fragmented, or siloed. For example, contact tracing and vaccination may need to be coordinated with one another to ensure that contacts are vaccinated promptly when they are identified. Coordination is needed not just for the deployment of established tools for responding to outbreaks but also for research into new tools that may take place in the context of an outbreak response. WHO’s research and development blueprint plays a key role in supporting coordination of research by prioritising research needs and facilitating collaboration.

CHIKWE IHEKWEAZU: At the state level, this coordination function is carried out by state epidemiologists and state disease surveillance and notification officers. They would work within each state to pull together the resources and financing required to respond to an outbreak. We have a certain number of sister public health institutes around the world– the UK’s Public Health England, Germany’s Robert Koch Institute. All partners are common and support. But the coordination of the response, the leadership, most of the financing at the federal level come through the Nigeria Centre for Disease Control. And at the state level, that is coordinated and managed by state epidemiologists and state disease surveillance and notification officers.

DANIEL CARTER: One challenge, of course, is to ensure that resources are deployed sufficiently and that this happens promptly and consistently. This does happen. For example, the Ebola outbreaks in DRC were fully funded very quickly. However, it is not always the case. And there are instances where insufficient funds are deployed, or where the funding is not commensurate with the potential or actual severity of the outbreak. There is also a tension between the deployment of funds into outbreak responses versus their use for other pressing needs, such as routine health systems financing. Spending on outbreak responses needs to be balanced against prevention of and preparedness for outbreaks before they occur.

Another challenge is that it is not enough just to mobilise funds into an outbreak. There is also a need for sufficient delivery capacity and mechanisms to convert those funds into actual activities to deal with the response. And in many cases, it’s not so much the lack of funding as the lack of this capacity or the absence of these mechanisms that hinder a response. This can be particularly the case in difficult operating environments, such as those that are affected by conflict.

One challenge is to strike the right balance between the coherence and focus of the response and making it as inclusive as possible in order to harness all of the available resources, delivery capacity, and expertise. The more actors you have in a response, the more difficult it may be to manage and coordinate.

Similarly, the single response plan does provide vital coherence. And yet, some actors may find it overly rigid, or constraining. This can be particularly the case where there are questions about the leadership and legitimacy of the governments in question. Indeed, it may be in situations in which the legitimacy of the government is in question or in which only non-state actors have access to the affected areas or population where coordination may be particularly difficult. Information sharing and mutual accountability are also essential for effective coordination but may be difficult to achieve. These require not only technical tools for data collection and analysis but also trust and transparency between the various actors involved. And this trust and transparency can take time to develop.

One thing that can help is through effective preparedness, which puts into place protocols for information sharing and reporting, but also helps to develop effective working relationships between the various agencies involved before an outbreak actually takes place. Outbreaks may require actors to work together when they’re not familiar with doing so, for example, between human and animal health sectors in the context of an outbreak of zoonotic disease. Multisectoral planning and preparedness work can help to establish, develop, and maintain working relationships between these sectors before they are actually needed in the context of an actual outbreak.

We have seen that systems for the funding and coordination of outbreak responses are essential and that country governments, WHO, and other actors all have a role to play. These systems enable effective outbreak responses to take place. But they also require prevention and preparedness work so that they are in place when they are needed.