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Ebola Emergency Response); on 23 May 2019, 10 months after the onset of the Ebola outbreak in eastern DRC, he appointed the United Nations Ebola Emergency Response Coordinator to oversee United Nations systemwide control efforts (61). In the 2009 H1N1 influenza pandemic the WHO Director General was more explicitly in charge, although the United Nations System Influenza Coordinator was also involved, which created confusion (62). Persistent challenges and obstacles International coordination mechanisms are not fit for purpose for health emergencies in complex environments It is unclear who will be in charge PROGRESS, CHALLENGES, ACTIONS: INTERNATIONAL COORDINATION MECHANISMS WHO leadership for health emergencies derives from the IHR (2005), but its convening and coordinating mechanisms are not sufficient to provide fully cohesive support for broad capacity strengthening in countries and for global outbreak response, or to ensure greater accountability of global preparedness. In addition, WHO lacks the systematic support it needs from the United Nations more broadly to tackle issues like security and trade pact violations that are beyond its scope (63). The IHR (2005) provide very focused criteria for activation of global resources under the designation Public Health Emergency of International Concern (PHEIC). However, the system lags behind in its ability to mobilize national and international resources and guiding multisectoral action early in an outbreak. The use of the PHEIC system is misunderstood by many stakeholders. Once a PHEIC has been declared, specific actions follow, including sharing critical information for risk assessment, adjusting response plans and implementing temporary measures, as necessary. The role of the PHEIC is limited to the late stages of an outbreak’s spread, and there are potential negative consequences resulting from a declaration (such as unilateral, ill-advised country actions to limit travel or trade) (64,65). Developing intermediate triggers before declaring a PHEIC would mobilize the wider national and international community at earlier stages of a response without interfering with the criteria for a PHEIC that met the needs of the IHR (2005) (66). WHO coordination and convening mechanisms are stretched No intermediate system exists for declaration of health emergencies at an earlier stage Required actions The United Nations must strengthen coordination mechanisms The Secretary-General of the United Nations, with WHO and United Nations Office for the Coordination of Humanitarian Affairs, must strengthen coordination in different country, health and humanitarian emergency contexts, by ensuring clear United Nations systemwide roles and responsibilities; timely triggers to rapidly reset preparedness and response strategies during health emergencies; and enhancing United Nations system leadership for preparedness, including through routine simulation exercises. WHO should introduce an approach to mobilize the wider national, regional and international community at earlier stages of an outbreak prior to a declaration of an IHR (2005) Public Health Emergency of International Concern. PROGRESS, CHALLENGES, ACTIONS: INTERNATIONAL COORDINATION MECHANISMS 28 Progress indicator(s) by September 2020 • The Secretary-General of the United Nations, with the Director-General of WHO and Under-Secretary-General for Humanitarian Affairs, strengthens coordination and identifies clear roles and responsibilities and timely triggers for a coordinated United Nations systemwide response for health emergencies in different countries and different health and humanitarian emergency contexts. • The United Nations (including WHO) conducts at least two systemwide training and simulation exercises, including one covering the deliberate release of a lethal respiratory pathogen. • WHO develops intermediate triggers to mobilize national, international and multilateral action early in outbreaks, to complement the existing mechanisms for later and more advanced stages of an outbreak under the IHR (2005). • The Secretary-General of the United Nations convenes a high-level dialogue with health,