A look at member states’ considerations, candidates plans for the future of global public health management and contemporary issues for the WHO.
Geneva, Switzerland: “Are you a political person?” one of the nominees for the position of director general (DG) of the WHO was asked recently. This question and the response to it is near central to understand what it means to lead the UN’s only policy-setting body. The role of the DG of the WHO is as much technical as it is political.
“Politics is about looking at the way in which power influences people and it is about using power to change their situation. We must always be skilled at engaging with all kinds of politicians to ensure that in the process they use their power for the political good,” David Nabarro, one of the nominees, told a motley crowd of international development folks that had gathered in Geneva earlier this month.
Whether it is leading coordination during emergency outbreaks or easing the access to medicines, setting standards for everything from dosage of vaccines to recommendations on salt consumption, or balancing the interests of developed countries – also its biggest funders – with those of the developing world, the actions of WHO affect everybody.
New political realities on either side of the Atlantic, the roles of specialised agencies, including product development partnerships, and the increasing power of philanthropes are continuously changing global health. Even so, the Geneva-headquartered WHO continues to play a pivotal role.
The expectations from WHO are exhausting – rallying support for universal health coverage worldwide, leading actions on climate change in the context of Sustainable Development Goals (SDGs), shaping an agenda on global health security and ensuring cheaper medicines, to name a few. The need for decisive leadership for the 7,000 strong organisation with staff in over 150 countries is crucial, given current and future challenges.
In May 2017, the vote to choose the leader in global public health, has, for the first time, been expanded to all 194 member states and not just the 34-member executive board, as has been the practice. This makes it open and unpredictable as never before. The new DG will assume office in July 2017.
The next leader will not only have to address critical concerns in global public health but also have to navigate politically difficult ones, including overhauling the structure of decision-making within the organisation and reducing political patronage, while having to battle budgetary challenges at a time of ever-increasing responsibilities and expectations.
To be sure, the responsibilities of fixing global health go beyond the DG of the WHO and also lie with the member states themselves.
But it is a good time to look at the candidates and the prevailing electoral dynamics that can throw up surprises, and a few crucial challenges awaiting the incoming DG. The Wire spoke to analysts, insiders and commentators in global health in Switzerland, the UK and Germany. Given the sensitivity of the issue, a majority of them did not want to be quoted.
The candidates and factors at play
In September 2016, member states announced their list of six nominees. In January 2017, WHO’s executive board drew up a shortlist of five candidates who were interviewed. The current nominees were shortlisted after that process.
Now, in the final run up to May 2017 vote, when the World Health Assembly will select the new DG to replace Margaret Chan, all eyes are on the three nominees – Ethiopia’s Tedros Adhanom Ghebreyesus, Pakistan’s Sania Nishtar and Britain’s David Nabarro.
The vote by the 34-member executive board in January this year saw Tedros with 30 votes, Nishtar close behind with 28 and Nabarro received 18 votes. What voting will look like among 194 countries in May is anyone’s guess.
“It is completely open who might win. There is no predictability and no pattern to go back and check. Much will depend on how the dice will fall,” an insider in Geneva said.
Commentators say that a strong leader at the helm of the WHO pushing for increasing world standards on protection of consumers and patients may be less preferable to some countries that might prefer status quo instead, possibly to safeguard their own interests or to be able to set their own domestic agenda without being pushed around by a decisive standard-setter in Geneva.
As with all negotiations at the multilateral level, there are highly specific and evolving geo-political considerations at play. And like other such opportunities, bargaining chips from outside the sphere of health may be used while making the final choice – a reality in foreign and global health diplomacy. Therefore, a complex set of factors will come to bear on how countries finally vote. Political developments and consequent implications for funding in the US and UK have changed calculations.
It is a riveting discussion in global health circles these days on whether Mexico will align with the American preference, whether all EU countries will vote for the British candidate post-Brexit or whether China will endorse the candidate from Pakistan.
Irrespective of public or private assurances by countries on their preferred candidates, it is impossible to tell whether they will indeed vote as they say they would, since the ballot is secret. “It is a revolution, democracy at its best. The system has become unintentionally competitive. The secrecy is important because it will safeguard choices,” the insider said.
This, some say, liberates the candidates to go into the election without fear or favour. One observer said, “The smart candidate will not attempt to buy support. Since the process is unpredictable, the best candidate can win without fear or favour.”
Previously, with the executive board making the final vote, large member-states could arm-twist smaller nations into aligning with them, sometimes reportedly in return for promises. It will be much harder to canvas support for a preferred candidate amongst 194 parties than it is among 34 executive board members. The smallest island state has the same voting power as any of the larger economies.
“The new election system is better than the previous one. Before larger donor states (eg US) could more easily influence the outcome. Now anything can happen,” Mathias Bonk, global health consultant and founding director of Germany-based organisation Think Global Health, told The Wire over email.
While no one is ruling out behind-the-scenes negotiations and promises, the vote is more democratic. Only the strongest will come to the fore, experts say.
This publicly fought campaign, everyone agrees, has been more transparent than before. These last few months have seen candidates respond to questions by country representatives, present their visions and deliberate at the Chatham House in London. An event in Geneva earlier this month was the latest such opportunity for the candidates to discuss their priorities.
Tedros Adhanom Ghebreyesus (Ethiopia)
The unofficial prevailing chatter in Geneva puts Ethiopian candidate Tedros in the lead, for now. A former foreign minister, who has also been chair of the board of The Global Fund, Tedros was also the health minister for Ethiopia. One observer in Geneva said, “He knows how money works and he can pick up the phone and call anyone because of his experience as both foreign minister and health minister”. It is understood that he is the preferred choice for some of the big member states.
Tedros has stated that “political buy-in” must come from the ground up and not in New York or Geneva. Pushing for universal health coverage, emergency preparedness and emphasis on women and children are top priorities for Tedros, who has a PhD in community health. He is the only non-medical doctor among the three candidates. His political experience is being seen as very valuable.
It is largely expected that the 54-member African Union will vote as a bloc for him, but that is not definite. Some believe the criticism of Ethiopia’s human rights record may be a factor. “Tedros cannot take any support for granted,” one expert said.
Sania Nishtar (Pakistan)
Nishtar is being seen as a “dark horse” or “the silent winner” in the race. Nishtar, a physician cardiologist, has also been a federal minister and has been on the board of immunisation agency GAVI – The Vaccine Alliance. She sees herself “a change-maker” with experience in governance and management, and is proud of her stint as “a minister in a country with 200 million people”.
She is largely acknowledged as a great communicator, fluent with details. Although popular, many are giving her only “an outside chance” to win.
Political considerations might not fetch her the required votes, experts feel. “It might be difficult for her to get the required votes in the first round, because of the anti-Muslim attitude of the current US government (main donor of WHO) and because of Pakistan being part of a rather small WHO region (EMRO, Regional Office for the Eastern Mediterranean)” one observer said.
Every country is hedging its choices, it is impossible to categorise votes at this stage, experts say.
David Nabarro (UK)
Largely seen as an insider, Britain’s Nabarro, a well-experienced UN-diplomat and a trained medical doctor, knows WHO “inside out”. He is the special advisor to the UN secretary general on the 2030 agenda for sustainable development and climate change. He has been deputed to battle a host of issues including avian and pandemic influenza, and combating Ebola. He has also been associated with initiatives on promoting food security and ending malnutrition.
Although he won the least number of votes of all the three current nominees in the previous round, where the EU vote was reportedly divided between France’s Philippe Douste-Blazy and Italy’s Flavia Bustreo, Nabarro could come up from behind in May.
In fact, one observer told The Wire that the northern countries see this as a last chance to reform WHO and hence are putting all their weight behind him. Nabarro is seen as able and proven.
But it is not clear if he is indeed a preferred choice. The Brexit vote may not help EU member states to align with him, experts say. Much will depend on the final decision of the big member states and the individual negotiations that candidates reportedly have with countries.
All three nominees are seen as very competent, but they do not differ significantly in their fundamental beliefs and priorities for the WHO. There is an emerging view that none of them have so far expressed being strong enough in their intentions to challenge member states if needed, once they are elected. The Wire reached out to all three nominees but received no responses at the time of publishing.
The question now is as much about who will win as it is about how he or she will deal with some of the challenges, once elected. So what are the key issues for the WHO, beyond these elections?
Key issues at stake for the WHO
The WHO is the only policy-setting global body within the UN system. There has sometimes been a conflict between this normative standard-setting role, its role on providing technical assistance to developing countries and its broader management functions, experts have said.
As mentioned earlier, there are two kinds of challenges facing the WHO. One is external to the organisation – a combination of issues requiring decisive leadership including access to medicines, engaging with the private sector and financing. Financing is also related to the second challenge – some say more difficult and largely internal – reforms in governance. But this obviously will impact how health policies are administered globally (think response to Ebola).
“Some of the most urgent tasks facing the new DG include financing of the WHO given uncertainty about US stance, WHO’s role in emergencies and dealing effectively with ‘new’ issues which are outside WHO’s traditional areas of expertise (non communicable diseases, climate change, etc.) and those that involve engaging with non-state actors,” Charles Clift, senior consulting fellow at Chatham House, told The Wire in an email.
While the WHO faces many challenges that are inter-linked, one of the most immediate is easing its pressures on financing. The organisation’s programme budget is serviced by both assessed and voluntary contributions.
More than 80% of the total funding comes in the form of voluntary contributions that are earmarked for spending, making it is less flexible for the WHO to respond in emergencies. It will be a priority for the new DG to increase the current 20% of overall funding which is not earmarked to pursue legitimate policy objectives in a nimble manner.
Assessed contributions are calculated relative to the country’s wealth and population, and such contributions are the dues countries pay in order to be a member of the organisation. Voluntary contributions can come from member states (in addition to their assessed contribution) or from other partners. “In recent years, voluntary contributions have accounted for more than three quarters of the organisation’s financing,” WHO says.
In October last year, current DG Chan drew attention to a $500 million funding gap in the WHO budget and an acute shortfall in the health emergencies programme of which only half was funded. (WHO’s proposed programme budget 2018-2019 is $4.4 billion.)
The uncertainty on funding is now further compounded by the new US administration’s stated position on budget cuts to the UN. The US accounted for more than 30% of the total voluntary contributions among member states to the WHO.
“It is indeed a modern paradox of increased expectations from WHO even as there is financial uncertainty. The next DG has to communicate effectively to make an investment case to get the necessary financial support. A new resource mobilisation strategy is needed,” Nishtar said in Geneva.
Resource mobilisation is important for the WHO, but how it goes about it remains contentious. Civil society organisations and other governance watchers have noted with concern the rise of the power of non-state actors including big philanthropes, some of which have funded health institutions and programmes across the world, dwarfing some national budgets for health.
A 2014 Chatham House report that Clift authored, says, “The Bill & Melinda Gates Foundation has in the space of one decade become the single biggest voluntary contributor to the WHO. Indeed by 2013 the foundation was the WHO’s largest funder, providing $301 million, which exceeded the United States’ combined voluntary and assessed contributions of $290 million.” (For 2015, the voluntary contribution by the US was $304.8 million and by the Gates Foundation was $181.2 million.)
A question on the expanding role of businesses and philanthropies went largely unanswered by the candidates at the event in Geneva.
Tackling emergencies is another important issue at stake. It is more or less acknowledged that the WHO has learned lessons from Ebola and has put a structure in place, which will hopefully also lead to timely response and coordination. But ultimately, stronger public health systems within member states are more important to prepare and counter any emergency, experts believe.
The WHO’s capacities to respond to emergencies is being touted as an increasing responsibility, since this also ties into the expanding agenda on global health security. But countries are divided on whether emergencies should become a core task for the WHO. This, some say, distracts the WHO from its more political responsibilities including protecting consumers from private sector interests which may not always be aligned with public health goals.
“There is an effort to outsource the more relevant normative work of the WHO, so that it can focus on emergencies,” an official from one of the member states told The Wire in an off-the-record chat in Geneva.
Politically difficult issues
Few issues divide WHO member states as those facilitating private sector participation or access to medicines. These will be important for the incoming leader to resolve.
The adoption of the SDGs has meant that the WHO has to take the initiative and put its expertise behind cross-sectoral issues beyond health, to matters that have ramifications for global health such as climate change, migration and non-communicable diseases.
Take non-communicable diseases, for instance. While fighting infectious diseases remains a priority, the burden of non-communicable diseases (cardiovascular diseases, cancers, diabetes and chronic lung diseases) falls disproportionately on low and middle-income countries that accounted for more than 75% of total deaths due to non-communicable diseases in 2012. The lobbying wars across countries are being fought on standards, norms and labelling rules.
It is a highly contested space, with the private sector fighting to get a seat at the table.
While acknowledging the need to bring the industry to the table, Nishtar said at the event in March, “WHO has to firewall its normative work from the many non-state actors which have to be and must be engaged in order to work on the Sustainable Development Goals. WHO needs to champion private sector competencies and tap into that as needed.”
While the WHO has to work with the private sector to solve the most intractable problems of our times such as finding new vaccines, how it will engage with the private sector without running into potential conflicts of interests is less clear.
Last year, the WHO adopted the Framework of Engagement with Non-State Actors (FENSA), to lay out processes to determine the participation of parties including the private sector, among other groups.
“The new DG should implement FENSA provisions in its letter and spirit and free the norm-setting activities of WHO in the area of medicines from undue influence. Often, the WHO’s norm-setting activities in the area of medicines are not transparent and not free from conflict of interest,” K.M. Gopakumar of Third World Network told The Wire on email. As an example, he cited how the WHO’s guidelines on biosimilars are heavily drawn from the International Council for Harmonisation, a body where originator company industry associations exercise decision-making powers.
During the discussion at the event in Geneva, Tedros said that the moral high ground is also important while working on FENSA.
While pricing is only a part of the access to medicines debate, it has become a big political issue in both developing and developed countries alike due to high cost of medicines.
But discussions around pricing have somewhat divided WHO member states into the developed countries that host pharmaceutical giants and developing countries that are home to generic drug producers.
To be sure, pricing is only one dimension to improve the access to medicines. Developing countries have been fighting to protect the larger public policy space, including by granting compulsory licenses or ensuring access especially in least developed countries with little or no drug manufacturing capacities. For developed countries, protecting innovation and intellectual property, improvement of health systems and streamlining of regulations are also seen as other approaches to improve access.
There is increasing recognition from the highest levels on the need to bring transparency into pricing by probing the links between the price of drugs and the cost of their production.
Apart from other multilateral fora such as the Human Rights Council and the WTO, the WHO’s role is critical in taking the lead on access to medicines. Some countries want the new DG to ensure that the WHO rises above alleged partisan interests while finding ways forward.
“Exercising effective leadership in areas where member states are very divided including FENSA, intellectual property, non-communicable diseases, will be important. The new DG must find ways forward rather than doing nothing and blaming member states for the impasse. Tackling access to medicines issues will be important since it has become a problem in high and low income countries alike,” Clift said.
Apart from the issues facing global health today, the DG must not only battle vested interests external to the organisation, but also take on political interests within the organisation. This, observers say, will be the most challenging.
“The hardest will be internal reform. The goal should be reform, without stating it as a goal. Reforms have to be the by-product of the actual programme of work undertaken by the DG,” one insider said. Just one example is the resource mobilisation strategy – departments will fight tooth and nail if they lose power to raise resources. “There are very strong, entrenched interests and a lot of resistance. There is a need to cut some more deadwood, much more than before,” he added.
This view is widely echoed. “Too much time is spent to discuss internal governance reforms, staff rotations, etc. Reforms are very difficult, but essential for the future of WHO. Restoring trust and aligning the work of its headquarters, regional offices, country offices and other global health institutions and actors will be key for the success of the organisation,” Bonk said.
It is hoped that the new DG will take steps to ensure that appointments at all levels in the organisation are more merit-based. Experts believe that WHO needs to earn the respect and trust to be the leading and coordinating authority in the field of global health again. “WHO has to find its voice, its role. They must aspire for a reduced role where they can add value,” one observer said.
This, the new DG can do by striking a balance between taking member states along and being assertive without being drawn in different directions from one year to another. “Better to start bold, state intentions and follow through, stay the course,” a former WHO official who has worked with one of the earlier DGs said.
It is not yet clear if any of the three candidates would overtly challenge member states, although they have all made statements stating the same. Of course, at this stage they would not want to rile states even before getting elected, experts noted.
“When asked to jump, I was not told how high I should jump,” Tedros said while talking about giving policy space to health ministers.
While talking about the Ebola outbreak, Nabarro stated, “Part of the role of being a DG is to take unpopular decisions. That will be inevitable. We need to move against the grain on how health systems operate.”
And Nishtar spoke categorically in Geneva when she said, “The era of niceties for WHO is over. There is a situation and we need to find solutions. …Politics is about building of institutions and speaking truth to power….”
Finally, the question of whether the WHO is losing relevance and whether countries are taking this election seriously appears to be a rhetorical one. There is a view that countries burdened with new political realities, migration and humanitarian crises are too distracted to pay attention to the election. “There are not enough countries today with the eye on the ball. So it does not matter to them,” one insider said.
But that may not be entirely true. For much of the developing world, the WHO continues to be the premier organisation where some of the most contentious fights in the coming years will be fought. “There is an undeniable ‘capillarity’ that WHO has. Countries look up to this,” a developing country official said.
Priti Patnaik is a Geneva-based journalist and researcher. She has previously worked as a consultant in the UN system including at the WHO. She can be reached at email@example.com