Strengthening European Leadership on Global Health Security

Impending leadership transitions in EU institutions provide a unique opportunity to bolster European action on global health security. This would be a double win for the EU: advancing its efforts to foster progress in developing countries while also protecting Europe itself against potential disease risks. To help strengthen the EU’s leadership on global health security, the new Commission should

• strengthen collaboration and coordination across EU entities holding global health security responsibilities;
• prioritise global health security and preparedness in the Commission’s dialogue with Member States;
• develop a financing mechanism to increase sustainability, collaboration, and effectiveness on preparedness as assessed by the WHO’s joint external evaluation process.

The Challenge

The 2014 Ebola outbreak in West Africa sickened more than 28,000 people and left 11,310 dead.^[1] As the outbreak spread through Guinea, Liberia, and Sierra Leone, disrupting markets, healthcare, and routine government services, the international community struggled to mount an effective response. The outbreak sparked a new wave of global health security dialogue, but five years later, epidemic and global preparedness for complex large-scale outbreaks remains tenuous. Despite some positive developments,^[2] global preparedness remains low, as exhibited by the difficulty of containing recent outbreaks, including the 2003 SARS outbreak;^[3] the 2015 Zika outbreak; and, most recently, the Ebola crisis in the Democratic Republic of the Congo and Uganda.^[4] However, pandemic preparedness is not just an issue for developing countries. In times of increased globalisation, interconnectivity, and global supply chains, health security is a truly global issue. Europe has a responsibility to protect its citizens from disease, which includes preparedness at home and abroad.

While much work remains to be done, a more structured global health security landscape is slowly emerging, as evidenced by the dedicated Sustainable Development Goal on health security (target 3.d); the creation of the World Health Organization (WHO) Health Emergencies Program and WHO Strategic Partnership for International Health Regulation and Health Security; the creation of the Africa Centres for Disease Control and Prevention (Africa CDC); G7 and G20 commitments to strengthen health security; and the creation of the Global Health Security Agenda, launched in February 2014 as a multi-sectoral effort to boost the capacity of countries to prevent, detect, and respond to infectious disease.^[5]

The WHO launched a joint external evaluation (JEE) process in 2016, providing a systematic tool for countries to assess outbreak preparedness across 19 technical areas and 48 indicators (with preventing, detecting, and responding as the core elements).^[6] As of July 2019, 100 of 199 countries have completed JEEs. However, in 2018, most countries scored below a four on the JEE indicators, “indicating non-sustainable or underdeveloped capacities.”^[7] (JEE indicators are scored from one to four, with one indicating “no capacity” and four “demonstrated capacity.”) Capacities are significantly more limited in Africa and South East Asia regions than in Latin America and Europe. While National Action Plans for Health Security (NAPHS) are being developed by countries to address gaps identified in JEEs, only 45 have been completed, and fewer still have been robustly implemented.^[8] While the slow progress on NAPHS implementation is explained by many factors, insufficient and inappropriately structured funding is a binding constraint.

In 2017, the International Working Group on Financing Preparedness estimated that $4.6 billion a year is required to finance preparedness,^[9] significantly less than the predicted economic loss of $60 billion per year if a pandemic occurs.^{[10], [11]} Responsibility for preparedness investments sits primarily in the hands of country governments, and the working group has recommended that governments both prepare investment cases and find ways to mobilise domestic resources for preparedness.^[12] A handful of countries have developed NAPHS-costed plans; however, competing immediate priorities of government health budgets and overall fiscal pressures makes investing in preparedness less urgent than other priorities that show immediate payoff. Building financing models that both mobilise international resources and create incentives for domestic resource investment is essential.

The European Union’s Added Value and its Progress to Date

The European Union (EU) has the advantage of being a supranational body with an established history of engagement in the global health space. The 2010 Brussels conference on the EU initiative “Global Health—Together We Can Make it Happen”^[13] led to a policy framework outlining the EU’s strategy and commitments to global health action.^[14] The Council conclusions^[15] from 2010 now serve as the main guidance for the EU’s global health operations, but mobilisation of the strategy has been slow and coordination challenges persist.^{[16], [17], [18]} While the EU has shown promise through the creation of the Health Security Committee^[19] and the 2018 Roadmap for preparation and response to epidemics,^[20] commitment to health security by EU Member States remains inconsistent.

EU Member States remain largely responsible for public health policy and service provision. However, Member States have agreed to work towards coherence with the EU on cross-border issues and beyond and it is here that the European Commission plays an important role.^[21] For example, while the EU is a member of the Global Health Security Initiative,^[22] only 10 EU Member States are members of the Global Health Security Agenda,^[23] and Finland is the only Member State that has completed an NAPHS. This gap is further evidenced by the spike in measles cases across Europe in recent years,^[24] leading to Germany’s recent decision to make the vaccination compulsory.^[25] Europe’s health preparedness must begin at home.

The EU institutions are currently punching below their weight on global health security. The European Commission’s role on health security is mostly limited to coordinating with Member States and supporting efforts of coherence among the Member States. This has resulted in health security priorities being managed in a segmented manner and coordination of health security objectives to be diffuse.

Currently, responsibility for different components of the health agenda are segmented across Directorate-
General (DG) offices. The EU’s mandate for pandemic preparedness lies across four of the Commission directorates, and one relevant entity: the Directorate- General for International Cooperation and Development (DG DEVCO), the Directorate-General for Health and Food Safety (DG SANTE), the Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG ECHO), the Directorate-General for Research and Innovation (DG RTD), and the European Centre for Disease Prevention and Control (ECDC). Although the current mandates and structures of the DGs may shift with the incoming Commission, understanding operations as they currently stand is vital to informing future policy.

• DG DEVCO facilitates preparedness, including financing, in low- and middle-income countries (LMICs). DEVCO also supports response during outbreaks, specifically through bilateral programmes with ministries of health that target health systems strengthening. However, there is not a specific funding mechanism or line item for preparedness and response; and financing of surveillance, labs, and other preparedness capacities is limited. Most of the finance is provided in the form of budget support without the direct, hands-on management and benchmarking of the improvement of health systems that are required.

• DG ECHO leads the response to specific outbreaks through the funding of NGOs implementing operations on the ground, including deployment of health personnel for health-related humanitarian operations. The EU has also established the EU Civil Protection Mechanism within ECHO, which aims to “strengthen cooperation between Participating States in the field of civil protection, with a view to improving prevention, preparedness and response to disasters.”^[26] Financial compensation is provided to EU Member States if they commit resources through the Civil Protection Mechanism, which is coordinated through the Emergency Response Coordination Centre.^[27] This mechanism can apply to pandemic response if activated.

• DG SANTE is responsible for preparedness in EU Member States and has strong links to Member States’ technical expertise and capabilities. It does not work in LMICs or play a role in facilitating the overseas deployment of Member State capacities.

• DG RTD is responsible for funding research in the context of infectious disease outbreaks, such as the Johnson & Johnson vaccine for the current Ebola outbreak in the Democratic Republic of the Congo. Additionally, DG RTD is responsible for the establishment of the Global Research Collaboration for Infectious Disease Preparedness.

• ECDC is responsible for monitoring disease threats and outbreaks, deploying epidemiologists in support of WHO, tracking surveillance and disease data, and delivering public health training programmes.^[28] The ECDC functions at the Member State level but also has international reach beyond the EU. In terms of response and to allow for the mobilisation of interoperable capacities, standards are set and checked by the ECDC. The ECDC’s “vision” in its 2020 International Relations policy includes supporting preparedness activities, including detection, assessment, and response to disease threats in neighbouring countries.^[29] The 2020 strategic objectives also include preparedness and response indicators, with the goals of strengthening partner countries’ preparedness and expanding outbreak response to countries outside the EU.

What Should the New Commission Do?

In the areas of health security, pandemic preparedness operations, and financing at the pan European and global levels, the new European Commission should seize the opportunity for strengthened cohesion and priority setting with Member States. Additionally, we encourage the new European leadership to help drive greater alignment and coherence in global financing mechanisms and payoff in the form of enhanced long-term health security for all EU Member States. To achieve these objectives, the new Commission should:

1. Strengthen collaboration and coordination across EU entities holding global health security responsibilities. Preventing and responding to high-risk outbreaks in both EU Member States and LMICs requires a more integrated approach to cross-departmental collaboration between relevant entities on global health security priorities. Each EU entity, including the DGs and ECDC, has a relevant comparative advantage—technical, deployment, financing, and more. However, efforts across these entities are fragmented, and siloed mandates can lead to gaps in coordination. For example, DG SANTE only holds responsibility for preparedness in EU countries, not LMICs, creating a divide between preparedness efforts that are led by SANTE and those led by DEVCO. In some cases, DGs are not cognizant of the functions of the different operating bodies. To date, inter-DG collaboration has been weak under the existing configuration and must remain a point of emphasis under any new configuration that emerges from the incoming Commission.

   The new Commission’s first priority for global health security should be clearly defining roles for each entity that is responsible for health and building linkages between interrelated capacities (e.g., ECHO’s overseas deployment capability and SANTE’s connections to Member States’ technical and operational assets), including a strategy and operational framework. The Commission could form a working group similar to the ET 2020 Working Groups,^[30] comprising leadership from the different entities, technical experts in the field of global health security, EU Member States, and ministry of health officials from developing countries, to develop an operational framework. Potential topics for the working group include preparedness responsibilities for each entity (e.g., DGs); portfolio of financing instruments and strategies to better support preparedness, including surveillance; and deeper and more formal engagement with African health security architecture, especially the Africa CDC.

   As a subsequent step, the working group could make nominations for an inter-commission health security steering group, which would broadly oversee the activities and coordination of the DGs. This group could also ensure that financing for preparedness is sustained and, in the case of a future outbreak, that there is a better tool for linking response efforts of the responsible EU body to the health workforce capacity of Member States.

2. Prioritise global health security and preparedness in the Commission’s dialogue with Member States. As public health remains a national competence for EU Member States, the Commission faces the challenge of encouraging Member States’ commitment to health security as a key economic objective within their own health priorities. As discussed above, Member States vary in their health frameworks, and may differ in their approach to health security and the importance assigned to that topic. Policy dialogue with Member States should include the states’ own health security as well as how they could best support others. Given the scale of challenges in pandemic preparedness and the global nature of many aspects of health security, a further alignment of Member States’ policies is crucial for Europe’s protection against disease risks.

   The framework resulting from the working group, described in recommendation one, should be socialised with and adopted by EU Member States. Moreover, DEVCO or another relevant entity (depending on the Commission’s structuring) should lead in encouraging Member States to join the Global Health Security Agenda and develop NAPHS.

3. Develop a financing mechanism to increase sustainability, collaboration, and effectiveness on JEE-scored preparedness. Investing in preparedness is a global public good that is currently neglected by most of the international system. Existing funding mechanisms—including the Pandemic Emergency Facility, the International Development Association, the Crisis Response Window, and the Regional Disease Surveillance Systems Enhancement Program—focus on outbreak response rather than preparedness. The new European Commission should build and support better financing mechanisms for international preparedness and response. The EU can build financing mechanisms for pandemic preparedness that closely link to measured progress, strengthened capacity, and overall sustainability. For development partners, trust funds are the traditional mechanism for providing health grants to countries. However, trust fund grants have not been successfully linked to JEE results. The new Commission should look beyond traditional funding mechanisms to solutions that prioritise measurement and results. Given the roles of the World Bank, the US Centers for Disease Control and Prevention, and bilateral actors such as Australia and China in providing direct financing support for preparedness and response, plans from the new Commission should consider existing financing mechanisms and how a synergistic approach can be assured.

   The Commission should align financial preparedness mechanisms with clear measurements, objectives, and incentive systems for efficiency, sustainability, and coordination. These measurements could utilise or build upon existing frameworks from the International Health Regulations. There are two primary goals of funding mechanisms for pandemic preparedness: to speed and sustain preparedness, and to increase domestic and international financing for preparedness in an efficient manner. In designing new financing mechanisms, these principles should be at the forefront of the Commission’s mind. Moreover, mechanisms should build incentive systems for efficiency and should increase the visibility and accountability of country governments.

   We recommend that the EU develop a “challenge fund,” a model that has successfully motivated countries to invest their own resources and focus on progress towards mutually agreed outcomes or reforms. A challenge fund could ask countries to put up a share (half) of the resources, with the other share (or half) coming from EU monies to fund preparedness gaps and programmes identified in NAPHS. Countries would receive half their contribution back if they make annual (or 18-month) progress on a set of independently verified metrics (could be a score 4 from the JEE). This arrangement could create incentives for domestic on-budget spending for preparedness, improve the quality of preparedness data by conducting a rigorous independent verification, provide opportunity for accountability at regular intervals, and help align multiple funders. For example, if other development partners, especially the World Bank, also designed their current funding mechanisms to be results-driven, the challenge fund mechanism could provide an opportunity for alignment of priorities, measurements, and accountability. This mechanism would also be helpful and appealing to country governments because it enables countries to “correct course” and “try again” if attempts to improve upon JEE evaluations are initially unsuccessful. In turn, this mechanism prioritises sustainability, a key objective for the EU, as it can build trust with country governments without tying funding to a single disease or outbreak.

All activities should take place in close consultation and collaboration with the WHO as the entity formally charged with the leadership and coordination of the International Health Regulations.