This is a guest post from Dr. Joshua R. Moon is a Research Fellow at the Science Policy Research Unit (SPRU), University of Sussex, researching biomedical research global health security policy. This post is based upon his PhD research, and further investigation into UN SGM Reports. Josh can also be found via his Research & Twitter

Donald Trump’s withholding of WHO funding, pending an independent review of WHO’s activities in the COVID-19 pandemic, has been lambasted around the world (some examples here, here, and here). In response, WHO Director General Dr. Tedros Adhanom Ghebreyesus said “In due course WHO’s performance in tackling this pandemic will be reviewed by WHO’s Member States and the independent bodies that are in place to ensure transparency and accountability … This is part of the usual process put in place by our member states.” This seems to be alluding to the WHO’s IHR Review Committee, a body which is enshrined in international law and is composed of independent experts.

On top of this, a proposal from more than 50 member states at the ongoing 73^rd World Health Assembly calls for “in consultation with Member States, a stepwise process of impartial, independent and comprehensive evaluation, including using existing mechanisms,  as appropriate, to review experience gained and lessons learned from the WHO-coordinated international health response to COVID-19.” This explicitly calls for the use of an IHR Review Committee in the text of the agenda item. The key questions are what is this mechanism, how does it work, and how can it provide the accountability and learning opportunity that Dr. Tedros seems to be referring to?

What is an IHR Review Committee?

The International Health Regulations (IHRs) are a legally binding international treaty to which WHO and its Member States (such as the US and China) are parties to. This treaty was revised in 2005 after almost a decade of negotiations, and stimulated by the experiences of SARS. The IHRs now includes various provisions for how to prepare and respond to an epidemic or pandemic. Plenty of analysis has been done on these revisions and how it impacts global health, this is not the purpose here.

Who sits on an IHR Review Committee?

The IHR Review Committee is made up of experts selected by the WHO Director-General from the IHR Roster of Experts. This Roster of Experts is made up of individuals with “qualifications and/or experience relevant and useful to the activities of [WHO]” (Article 47 of the treaty). All WHO Member States also can request an expert for addition to the IHR Roster of Experts which the Director-General must appoint. The IHR Review committee may also include other experts not on this roster, if their expertise is deemed useful.

What does an IHR Review Committee do?

The IHR Review Committee is enshrined in Part IX, Chapter III of the treaty (Articles 50-53) which outline the scope of the committee, its conduct and composition, and how it should report. At its core, the IHR Review Committee is a review of the IHR treaty, not the WHO itself – but as we shall see in previous IHR Review Committees, the two are not necessarily all that distinct.

The function of this committee is to provide technical recommendations and advice to the Director-General. The committee functions through conducting a number of meetings where evidence is heard and questions asked, rather like a Public Inquiry or Congressional Hearing. There is also a Secretariat that sits behind these deliberations which provide technical information and help the committee access people for testimony.

At the end of the process, the IHR Review Committee sends a report to the WHO Director-General who then transmits this to WHO Member States via either WHO’s World Health Assembly or the WHO Executive Board. Once this is done, the report is considered and actions are taken based upon these recommendations.

Previous IHR Review Committees: H1N1 and the 2014 Ebola Outbreak

IHR Review Committees have previously been held after significant outbreaks of disease in 2011 (reviewing the H1N1 Pandemic) and in 2016 (reviewing the 2014 Ebola Outbreak in west Africa). An IHR Review Committee was also held in 2014 which considered second extensions to the implementation of IHR Core Capacities, but this is out of scope for what we are discussing here.

The IHR Review Committee in 2011 reviewed how the IHRs functioned in the 2009 H1N1 Influenza pandemic. While the findings of the review generally concerned the IHRs, a whole section of the report was dedicated specifically to the review of the work of WHO during the pandemic. These findings included strengthening WHO capacity to respond, WHO strategic communications, and pre-made agreements on vaccine and data sharing.

The IHR Review Committee in 2016 reviewed the 2014 Ebola Outbreak in west Africa and included a number of recommendations for WHO. These include strengthening WHO capacity to respond, reviews to WHO’s risk communication and risk assessment, and improving data sharing and sample transfers.

The IHR Review Committee is not the only mechanism by which WHO is evaluated. During the Ebola outbreak, an Ebola Interim Assessment Panel was convened by WHO to assess its own response to the outbreak. The assessment noted how all levels of WHO needed to ‘undergo significant transformation’ and recommended that WHO’s capacity to respond should be strengthened, that WHO must be the authority in communicating during emergencies, and that WHO must play a central role in research and vaccine development. This was echoed by multiple other reviews like Harvard-LSHTM, UN High-Level Panel, and the US National Academies of Medicine.

Each of these instances recognise that accountability is key and that we must learn lessons from these catastrophic events. Given all of this, however, the lessons from each remain startlingly similar. The received wisdom of why is a fear-apathy cycle and a lack of implementation of lessons. The fear-apathy cycle is exactly like it sounds, apathy towards pandemic preparedness between outbreaks, punctuated by panic and throwing large amounts of resource at response during an epidemic. This leads to a lack of implementation because institutions cannot depend on consistent funding to implement recommendations.

How can an IHR Review provide accountability and learning?

If the world is consistently apathetic to funding long-term solutions to epidemics, how can accountability and learning actually be fruitful from these kinds of exercises? Three ways: first, recognise their political nature; second, be transparent and inclusive on the evidence-base; and third, communicate and disseminate the findings even after the report has been published. Each of these are related to one another and inform one another, but we will start with the first and most important.

IHR Reviews are political

WHO tends to shy away from the idea that it is a political body and in particular the IHR Review Committees should “(a) make technical recommendations … (b) provide technical advice … (c) provide technical advice” (Article 50 of the treaty). This emphasis on the technical nature of the committee is in line with this reluctance to engage with the international politics of global health. However, it cannot be escaped that these reviews are political.

The politics of accountability and blame in these reviews cannot be avoided. During the Ebola outbreak, WHO was heavily criticized for its delayed response and poor leadership. The review therefore had multiple tasks in front of it: evaluate the response, apportion blame for the failings of WHO, and apportion blame for other failings in the response. This is not, and cannot be, purely technical.

On top of this, emphasis on the technical aspects places any issues or problems into the realm of ‘experts.’ This has the effect of narrowing the definition of what is ‘in scope’ for the review, and conflates technical and political aspects of response into technical decision-making. By focusing in on making technical recommendations, the IHR Reviews don’t just shy away from the politics of accountability but mask those politics underneath a technical surface.

The Ebola Interim Assessment Panel already did this in part, by recognising that WHO constitutes not just its secretariat but the member states. In making this political choice to expand its own terms of reference by opening up the definition of WHO, the Interim Assessment Panel was able to make recommendations not just at the secretariat level but the member states themselves. This was only possible because the panel was given the freedom to interpret their own mandate. In doing so, the panel were then able to criticise states’ underfunding of WHO and not following technical advice.

Further to this, the Ebola Interim Assessment Panel was acutely aware of its own position within a series of other evaluations. This enabled the panel to make recommendations for further investigation in other reviews. My research also demonstrates how central a role this played in shaping the agendas of other reviews, reinforcing those lessons-learned. By recognising that the panel’s evaluation held a position as the first review, and that it was not independent of the politics ongoing around the outbreak, the panel shaped the lessons-learned across many of the UN-level evaluations.

Transparent and Inclusive Evidence-Base

A transparent and inclusive evidence-base on the surface does not sound like a novel idea. However, when we combine it with accepting the political nature of these events, we can see how expanding the definition of evidence beyond a technical understanding can shift the ability of the IHR Review Committee to be transparent. By focusing on technical questions, there is an obfuscation of political issues that may be more effective at solving problems.

What can be done to create a more transparent and inclusive evidence base once you accept the political nature of the review committee? For a start, evidence needs to be collected during the response, as well as after. By collecting evidence as it happens, and discussing issues in-context, the review committee can explore the full complexity of response decision-making. This requires an acknowledgement that accountability and transparency is required not because there is blame to apportion, but because there is a social and political need post-crisis to analyse and understand why the crisis happened.

In addition, by acknowledging the review process as political, there is an acknowledgement of the need for an inclusive evidence-base. This means that evidence is needed from a diversity of academic disciplines, from non-experts, and from different member states. In particular:

• Visits by the IHR Review Committee to field sites, and evidence being collected from local areas affected by the epidemic is a much broader view of knowledge and evidence that opens up the local politics of epidemic response.
• Discussions with economists, sociologists, political scientists, international relations, anthropologists, medical historians, etc. (including on panel membership) will enable the IHR Review Committee to consider multiple perspectives on the response which may feed into political responses

It is likely that much of this evidence like site visits and state-level data will depend upon the cooperation of states. This may run into some problems when states do not want to share this level of information with an institution over which they have limited control. However, by being transparent about what data is being included, states may be pressured into providing evidence if other states are doing the same. Additionally, recognising an inclusive evidence-base means that some of the missing data may be approximated by other sources even if states restrict official data access.

Effective Communication and Dissemination

To borrow a phrase from a panel chair that I interviewed for my research: a report is not the end of the process, it is the start. Once you recognise the review process as political, the recommendations of the review stop being technical advice and become policy options that can be advocated for. What this simple shift in perspective demonstrates is the importance of communication and dissemination in implementing the recommendations of a review panel.

In essence, the members of the IHR Review panel need to not just be qualified technically, but need to be effective communicators and advocates for change. In particular, by having more effective communication and political advocacy, the recommendations are disseminated to political spaces, costed, negotiated, and fed into longer-term political processes. This can be done not just through the current press-release format but in longer-term political advocacy in national governments as well as at an international organization level.

On top of this, the IHR Review panel should be acutely aware of the format of the report itself. In an article understanding reporting for UN Secretary-General’s Mechanism Investigations into alleged use of chemical and biological weapons, my co-author Caitriona McLeish and I look at reporting in a highly political environment. We find that reporting in these environments depends on recognising that reports are in-effect a performance that seeks to involve the audience in decision-making. This requires the report to therefore engage its multiple audiences in highly divergent ways, reframing the report from simple technical communication to a boundary object bridging science and policy.

An opportunity for WHO

An IHR Review Committee presents an explicitly and inescapably political opportunity for WHO to learn lessons and re-assert itself. This includes shifting away from a purely technical framing of the review itself, looking into social and political dynamics as well as technical issues. WHO must also look wider than medical and clinical advice to broader aspects of context and complexity in decision-making and the impact of those decisions. However, all of this requires WHO to accept the political nature of this review and lean into it, rather than shying away from politics as it normally does.

Given the exigency of the 73^rd World Health Assembly, and the resolution calling for a review of the response, the IHR Review Committee is likely to be called for in the coming days. This therefore will require the investigation be conceived of immediately, asking questions of who will be on the panel, what will they investigate, and when will it begin. If the political nature of this panel is to be recognised, then the answers to these questions become slightly clearer:

1. Who? A small panel of experts across multiple disciplines, including social science and nursing, with a range of political affiliations (with President Trump in office, this may have to include a representative from China and the US).
2. What? The panel should be given broad terms of reference which reflect the needs of WHO, whilst being given the freedom to interpret those terms liberally
3. When? The review should begin collecting data and evidence immediately, holding open deliberations and preparing to report and communicate in the very early stages of recovery to help enshrine lessons into policy while the window is open.