‘Confident of Victory Due to My Experience’: Nepal’s Candidate for WHO Southeast Asia Office

In an interview to The Wire, Shambhu Acharya answers several questions ranging from Ayushman Bharat, health financing models, and WHO's engagement with governments in the Southeast Asia region.

New Delhi: The election for the head of the South-East Asia Region (SEAR) office of the World Health Organisation (WHO) is scheduled to be held on November 1, 2023.

It is a hotly contested election in which two candidates are in the fray. One of them is Saima Wazed, the daughter of Bangladesh’s Prime Minister Sheikh Hasina. Wazed holds a specialist degree in school psychology and has worked in the field of mental health since 2014 with various institutions.

The other candidate from Nepal is 65-year-old Shambhu Acharya. He has a PhD in public health. He has served in various organisations, including the WHO and World Bank, in wide-ranging areas of public health. He has also been an adjunct faculty member at a couple of universities.

The SEAR consists of 11 countries, including India, and each of them gets a vote. Myanmar is not eligible to vote because of its political environment. If there is a tie after the first round of polling, then there would be subsequent rounds, till there is a final result.

The Wire’s Banjot Kaur caught up with Acharya in Delhi to understand his views on various health issues about the region, in general, and India in particular. Excerpts from the conversation follow. In square brackets are the author’s clarifications.

How confident are you about your victory? 

I’m very confident. First, I have a very solid public health and technical background and I am an academic with a PhD degree. I started my career with community-based medical systems and then moved up the ladder and occupied different leadership positions, even managing some institutions. I have also worked with the WHO at high levels. I have not focused on just one area of public health but a number of them. I have worked as a scientist, technical officer, manager, and director. This gives me a whole range of experience that this post [of the SEAR head] would require.

Do you think your opponent is at a disadvantage because she doesn’t have a vast experience like you do?

I can’t say that. The CVs are in the public domain. That is for the people and the member states to decide.

There are charges of nepotism against your opponent. What is your opinion on that? Also, it’s said that this is the first time that the kin of a government’s head has applied for an elected post at the WHO or even any other UN agency.

To answer your first part, I do have a personal opinion but I will give it a pass because it is against the model code of conduct [of the WHO elections] to make such personal comments. On the second part, as a matter of fact, it is correct.

Sheikh Hasina and Saima Wazed with Joe Biden and Jill Biden. Photo: X/@drSaimaWazed

The SEAR has the highest burden of many diseases. Also, it is home to the largest number of people suffering from undernourishment and these challenges make the region different from others. How do you plan to address them?

These circumstances exist because we [SEAR region] have a quarter of the world’s entire population. That’s exactly why we have to look at it from the opportunity point of view. This is also the reason why [the region] is economically growing faster.

Do you believe fast economic growth has trickled down to all the masses?

It is trickling down. If you look at India, for instance. India had 1% of GDP investments in health in 2014. Nowadays, it’s over 3%. [More on this later.]

According to you, what are the major challenges for the SEAR as far as public health systems are concerned?

I would just not talk about the treatment but also the prevention. So, we need to make sure that education for health becomes the priority for everyone so that people know what are the consequences of ill health.

But people do know them to a great extent. Their major concern is about ‘access’ to health or the lack of it.

No, but that’s only when you get sick. You can also do something before you get sick by improving your lifestyle. A social movement is needed for that education.

Such campaigns already exist. How do you plan to add value?

I want to go to the individuals – the youth and women – to give that message. And [also want to ensure] we get each and every citizen must have access to health.

Where do you see the role of WHO’s SEAR Office in enhancing access to health when, essentially, it is the government’s responsibility to provide that?

The WHO can provide the necessary guidelines and policy advice to the governments. We need to build on this through advocacy with political leaders.

So, how do you remodel your dialogue for this? 

What I will say is that the budgets, or health expenditures, should not be just viewed as a ‘cost’ to the government. It should be viewed as an investment in human capital.

In this region, and especially in India, access to health is not the only issue. Even the quality of healthcare being provided is also an issue. How do you plan to address that?

India, and largely the SEAR, provides good quality tertiary-level healthcare, and has, therefore, become a hub for medical tourism.

But then we also need to focus on [the quality of] primary and secondary level healthcare, [in peripheral areas and small towns]. We should have a quality workforce there along with medicines and diagnostics. The majority of services can be given at the two lower levels of healthcare itself.

As a WHO representative, I would try to engage with the highest level of political leadership in this direction. Different member states of the SEAR can learn from each other, too, in providing primary healthcare. Your Ayushman Bharat programme is a good example of that.

Despite so many reports and various engagements at all levels between non-governmental organisations and the government, India’s expenditure on healthcare remains one of the lowest. Where do you think things went wrong?

But it has reached 2.5% of the GDP and I think it is an increment in the right direction. As a matter of fact, according to the Economic Survey 2022-23, the actual expenditure figures are available for 2021-22. For that year, the central and state government’s combined expenditure on health was 1.6% only. The revised estimates for FY 22 stand at 2.2% but the actual expenditure would be available only next year. Since 2014, health expenditure has steadily risen, you see.

Why do you compare it with 2014?

Because there has been a steady rise [in health expenditure] from 2014. [According to the last Economic Survey, health expenditure as a percentage of the GDP in 2015-16, 2016-17, 2017-18, 2018-19, 2019-20 and 2020-21 was 1.3%, 1.4%. 1.4%, 1.4%, 1.4% and 1.6%, respectively. The actual expenditure figures are only available till 2020-21.]

The Indian government, and a few others, too, lay a lot of stress on insurance-based health financing models while some others feel that creating a health infrastructure is better. What is your opinion?  

I don’t think there can be a scenario of one versus the other.

One model is, for example, that of the UK, France, etc., where each and every citizen will have access to health services from the government. The other one is about health insurance, in which you talk about pooling resources from each individual, cross-subsidising from the rich to the poor, and helping the latter through insurance. That has worked well in countries like Germany and Thailand.

But Thailand spends a lot on healthcare. Unlike India, where only one-third of the health expenditure comes from the government, in Thailand, the government’s share is two-thirds.

The whole idea is to finance in a manner that people are not pushed into poverty due to expenses incurred on healthcare. Countries like Japan and Thailand also took 40 to 50 years to achieve the best of their health financing models.

You spoke about the Ayushman Bharat programme. But there is also a decent amount of criticism against it for not being able to cover a large chunk of the population. And recently, a CAG report highlighted large-scale corruption. Do you still believe it is the panacea for India’s health problems?

I mean, I do not want to say whether it’s a panacea or not, but what I’m saying is that covering 500 million people [under the programme] –  that we know is one of the largest –  is a great achievement. So, I’m sure India has a plan to cover more. Everyone gradually will be covered.

Though the government, so far, hasn’t made public any such intention of covering the entire population, the programme is also criticised for having diverted its attention from creating better health facilities to investing in insurance schemes as a proxy…

You are mixing two things here. Insurance is essential for providing income to health facilities. And once there is income, infrastructure and various issues can be improved. Infrastructure does not exist in isolation.

So, the government can still invest in infrastructure [while funding insurance-based programmes].

Representative image. Photo: Yaqut Ali/The Wire.

There is a lot of diversity within the SEAR, and therefore, every country has a health problem unique to its own. How can you bring synergy amidst all of this?

Yes, there exists a lot of diversity but the principles like universal health coverage are the same. So, while I don’t intend to implement a one-size-fits-all formula and stress for a tailored approach for each country, there is a lot that these countries can learn from each other depending on their specific challenges. For example, NCDs for India, climate change for Maldives, migration for Japan, etc.

The SEAR, in the coming decades, would be home to the most ageing populations. This is not only going to create a challenge in terms of access to health, again, but also, otherwise. What is your prescription to deal with that?

This is a very important question. Japan and Singapore are good examples to learn from, in this regard.

But firstly, we have to make sure that ageing is recognised and acknowledged as part of our health policymaking. Primary healthcare has to be strengthened for the elderly. Besides physical care, programmes for their [ageing population’s] psychological and emotional care have to be incorporated as part of the programmes for them.

Secondly, to see to it that the elderly age in a healthy manner, especially in a country like India, where the burden of NCDs is already high, we have to provide them an active lifestyle, and opportunities to work, if they are interested, even when they are not a part of workforce as such.

Lastly, I want to ask about a challenge that is somewhat unique to India, which is unbridled to a large extent, the unscientific use of various alternative systems of medicine products. How big a problem is this for you?

Traditional medicine is important but at the same time, it has to be based on very good, proven, and scientifically robust research with good evidence, definitely.

Are the governments doing enough to implement in practice what you just said?

There has to be the right kind of legislation in place, and more importantly, right and constant messaging – that anything [a drug or a supplement] has to be consumed only if it passes the scientific muster. Mass awareness programmes are urgently needed for this, and the youth has to be engaged.

But not everything can be done by the governments. If there is evidence saying something is not good to be consumed and if one is still hell-bent on doing that, then there is a problem. [It’s] a challenge in terms of behavioural science, dealing with which requires a lot of engagement with the community.