The World Health Organization

The World Health Organization (WHO) was the first, and today remains the leading, multilateral organization for responding to infectious disease threats. It was established in 1948 as a specialized agency within the United Nations. The WHO is governed by its 192 member states through the annual World Health Assemblies (WHA) held at its headquarters in Geneva. The WHA sets policies and provides the overall governance of the WHO. The WHO also has an Executive Board, composed of 32 members technically qualified in the field of health, that prepares work programs for WHA, provides technical advice, reviews finances, and decides on actions on disasters and epidemics. The WHO is further divided into three levels - headquarters, relatively autonomous regional organizations, and the 142 country offices. This division reflects the WHO's origins as an amalgamation of several organizations dealing with health. Its member nations are grouped into six regions: Africa, the Americas, South-East Asia, Europe, the Eastern Mediterranean and the Western Pacific (Minelli, 2003).

At the time of writing, the WHO operates in three management clusters and seven technical clusters: Communicable Diseases; Non-communicable Diseases and Mental Health; HIV/AIDS, TB and Malaria; Sustainable Development and Healthy Environments; Health Technology and Pharmaceuticals; Family and Community Health; and Evidence and Information for Policy. With the exception of HIV/AIDS, tuberculosis and malaria, and immunization and childhood vaccines, all WHO's epidemic-related activities fall under the auspices of the Communicable Disease Cluster - and, more specifically, under the Department of Epidemic and Pandemic Alert and Response. Initially the WHO's budget was based on member contributions, which were determined by a formula based on population size and gross national product (Walt, 2005). By the 1970s, high-income member states had raised the level of extra-budgetary funding for specific projects. Increasingly seen as donors, their influence grew, challenging the WHO's relative autonomy. By the 1990s, close to 54 percent of the WHO's funding came from extra-budgetary sources, compared with 25 percent in 1971.

Some have raised concern that a few wealthy donor nations are exerting undue influence on priority-setting (Walt, 2005). It could also be argued that creating disease-specific organizational components undermines efforts to integrate disease surveillance and strengthen health systems in low-income countries. For example, while the WHO has a Communicable Diseases Cluster, a separate cluster has been created for HIV/AIDS, TB and malaria that now receives more funds than other infectious diseases.

Early on, the WHO decided against creating its own research institutions, and instead to take advantage of existing research and education organizations in member nations. These partners, called WHO Collaborating Centers, constitute elements of a cross-institutional network to support its programs at every level. The centers also participate in strengthening the national capacity of the health systems by assisting in data collection, research, training, and providing health services (WHO Collaborating Centers, at http://whqlily.who.int/). While the WHO's Collaborating Centers on various infectious diseases provide important research data and sentinels around the world, there has been criticism raised that the large number of agencies and organizations on the ground has also created confusion and even chaos (Shoo, 2000; Enserink, 2004). Responding to this criticism, especially to the handling of the Ebola outbreak in Kikwit, the Democratic Republic of the Congo, in 1995, and that of Rift Valley fever in East Africa in 1997, in 2000 the WHO launched the Global Outbreak Alert and Response Network (GOARN) (Enserink, 2004). GOARN's mission is to improve coordination in the field and within the organization by functioning as an operational platform for pooling human and technical resources, and linking this expertise to needs on the ground. The Department of Epidemic and Pandemic Alert and Response manages the network, and links more than 130 laboratory and surveillance networks around the world in order to identify and verify pathogens rapidly, and to coordinate the overall international response to disease outbreaks. GOARN'S partners include government agencies, ministries of health, academic centers, and UN agencies, as well as networks of military laboratories and NGOs located in areas with high risk of epidemic outbreaks. GOARN responds to more than 50 outbreaks a year (Drager and Heymann, 2004; Heymann and Rodier, 2004).

The WHO also works through GOARN to improve global, regional, and national preparedness and response to contain epidemics, emerging diseases, and drug resistance. It helps to establish surveillance standards, create regional or sub-regional preparedness and rapid response networks, improve laboratory capacity, establish laboratory networks, and provide training in field epidemiology and assessment and strengthening of national surveillance systems (Epidemic and Pandemic Alert and Response, at http://www.who.int/csr/en/). It also provides manuals, guidelines, and checklists to assist in prevention, detection, and response activities. In addition, the WHO provides collaborative risk assessment, and communication and ongoing advice on infection control.

Realizing it lacked an operational component for managing information and field deployment for rapid response operations, in 2004 the WHO established the Strategic Health Operations Centre (SHOC) to coordinate epidemic response at its headquarters and in the field (Nebehay, 2005). In the event of an outbreak, SHOC becomes a high-tech global command center, and the operational hub of global alert and response activities of GOARN and others. The 2004 Asian tsunami became the first crisis in which SHOC was fully operational, functioning as the virtual and physical place where teams from across various WHO health clusters came together to coordinate an agency-wide response. It served as a focal point for daily briefings, operations and facilities planning, and communications and coordination with the WHO Regional Office for South East Asia, other UN agencies, non-governmental organizations, and member states.

The WHO and its partners have created several tools to support epidemic response activities, including the Global Atlas of Infectious Disease, which provides GOARN members and other networks with an up-to-date interactive single electronic platform to map infectious disease outbreaks. Another example is the Global Public Health Intelligence Network, developed and run by Health Canada, which provides the WHO with a computer-based tool that continuously scans websites, online news services, public health discussion groups, and e-mail services for information that could signal potential disease outbreaks. The WHO has also made efforts to integrate infectious disease programs into health-system development. A good example is the Integrated Disease Surveillance and Response (IDSR) program to help establish nationally owned and maintained disease surveillance systems capable of collecting and reporting data. Implementing such systems worldwide would significantly enhance global capacity to develop plans and public health interventions.

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