Crisis bill due: Who will pay for Ebola?

Crowdfunding won’t work. An epidemic just isn’t cute, and the year-old Ebola epidemic in the Democratic Republic of Congo (DRC) mostly doesn’t tug on heartstrings in developed countries. And the sums of money needed are staggeringly large.

The World Health Organization recently declared the 2018-19 Ebola outbreak in the DRC’s North Kivu and Ituri provinces a public health emergency of international concern (PHEIC).

Two recent Ebola outbreaks followed different trajectories. In 2014-16, more than 11,300 people died in Sierra Leone, Liberia and Guinea. In contrast, with help from the Merck vaccine, the 2018 outbreak in the DRC’s Équateur province was halted in three months after only 33 deaths.

Early indications suggested that an extensive vaccination campaign might quickly end the Kivu-Ituri outbreak. But local conditions – including tribal conflict and distrust of health workers – are making the current outbreak resemble the protracted West African epidemic. 

By July 22, the DRC ministry of health had recorded 1,743 deaths, with a case fatality ratio of 67 percent.

A PHEIC “is not for fundraising,” Dr. Tedros Adhanom Ghebreyesus, WHO’s director general, stressed in his announcement. Labelling an outbreak an emergency doesn’t automatically release any funds. 

Yet financial support is badly needed, and Ebola experts and aid organizations may expect Tedros’ declaration to accelerate the flow of funds. Although details are still being worked out, Mike Ryan, WHO’s director of emergency operations, estimates core operations will require $233 million. The WHO has received only $44 million of the $98 million needed through July.

Non-government organizations also face critical shortfalls. The Red Cross/Red Crescent, for instance, has received less than half of the $31.2 million needed for its work.

Without additional funds, the WHO and humanitarian organizations will have to curtail critical activities, closing centralized treatment centers rather than opening additional facilities closer to people’s homes, thereby permitting Ebola to spread.

As a point of comparison, halting the 2014-16 West African Ebola outbreak cost more than $4.3 billion. Other sources put the price at $5.6 billion for the U.S. alone.

For researchers like me who study global health governance and arrangements for combatting epidemics, inadequate funding joins delayed reporting and information suppression as a key concern. And although the 2005 revision of the International Health Regulations (the treaty governing global health surveillance) improved reporting and tracking, it did nothing about the funding situation.

To be sure, tracking flows of funds for massive public health campaigns is challenging. Early estimates often grossly underestimate the ultimate cost of controlling an epidemic. Estimates also are inconsistent in what they include as a cost.

Lower estimates might include the expenditures of only the WHO and a few core partners, excluding expenditures by NGOs. Lower estimates might include only direct costs of fighting an outbreak, omitting spending on local health infrastructure or global disease tracking.

Global public health campaigns draw on direct and in-kind contributions from an astonishingly large group of donors. More than 60 major donors supported the WHO’s work on the West African Ebola outbreak.

Contributions from the United States (the largest donor) were funneled through a variety of U.S. government agencies. And the WHO’s count didn’t include donors who contributed to Médecins Sans Frontières, Samaritan’s Purse and other NGOs.

This complex and unreliable funding stream can make planning and coordination difficult. What can be done to shore up funding for global public health?

Although member states are obligated to contribute to the World Health Organization, only 18 percent of its budget comes from assessments. The remainder consists almost entirely of earmarked voluntary contributions from member states and nonstate actors. Yet donors, including the United States, do not reliably make promised or assessed payments.

Philanthropists sometimes fill funding gaps but with mixed results. Their contributions are certainly welcomed, as is their capacity to act quickly and boldly. Yet because megagifts can convert private wealth into public influence, they pose a threat to democratic institutions and can reduce pressure on governments to provide basic goods and services or to create the core capacities that are an “indisputable baseline for global health security.”

Already concerned about the outsized influence of the Gates Foundation, whose grants “do not reflect the burden of disease endured by those in deepest poverty,” analysts are even more alarmed about accountability when donors give through limited liability companies, such as the Chan Zuckerberg Initiative, rather than through more closely regulated charitable foundations.

Worried that delayed, inadequate and inappropriately targeted funding have allowed epidemics to spread, the United Nations, the WHO, the U.S. government and other entities have begun developing alternative funding mechanisms.

Acknowledging that the security implications of some health emergencies necessitate additional funding and better coordination, the United Nations created a Mission for Ebola Emergency Response during the 2014-16 West African Ebola outbreak. In a similar spirit, in 2015 the WHO created a Contingency Fund for Emergencies to permit more nimble responses to health emergencies.

Despite these initiatives, the funding crisis continues. Just days before the Kivu-Ituri Ebola outbreak was declared a global health emergency, Mark Lowcock, the UN emergency relief Coordinator, warned that “unless there’s a big scale-up in the response, we’re unlikely to be successful in getting to zero cases” of Ebola.

Only with reliable funding for responding to emergencies and building core capacities can the International Health Regulations make global health security a reality.

Kickstarter campaigns have a place, but crowdfunding and philanthropic contributions are not the way to fund something as vital as global public health.

Carol A. Heimer is professor of sociology at Northwestern University and research professor at the American Bar Foundation and a public voices fellow through The OpEd Project. Her research focuses on HIV and other global epidemics.