Geneva: After the historic elections at the World Health Organization (WHO) that saw the first ever African be elected as director general (DG), Ethiopian public health leader Tedros Adhanom Ghebreyesus has got down to business, appointing his senior leadership team, aided by advisers and a transition team, as he works on setting priorities and ushering in administrative changes at the global health policy-setting body.
In a first for India, Soumya Swaminathan, a highly respected paediatrician and internationally known researcher who has worked on tuberculosis and HIV, has been appointed deputy director general for programmes (DDP). The DG will also be assisted by Jane Ellison, deputy director general for corporate operations (DDC).
The new team – represented by 14 countries, with more than 60% women – is expected to take charge over the coming weeks. A new programme of work is being discussed at various levels of the institution and will be taken up at a special session of the 34-member executive board (EB) that will be convened later this year in November. Tedros, known by his first name, assumed office on July 1 this year.
Although it is still early to get a sense of the new administration, there are some initial indications. Like all new leaders who take charge at global organisations, Tedros will have a limited period of time to push through his goals for global health. Many are waiting to see the direction the institution will take under the new leadership.
The key people
In an email to his colleagues on October 3, Tedros said that his new senior leadership team includes former ministers of health, some of the world’s leading physicians, scientists and researchers, and programmatic experts in universal health coverage, health emergencies, communicable and non-communicable diseases, climate and environmental health, and women’s, adolescent and child health. Individually and collectively, they have a wealth of experience across government, private sector, multilateral, civil society and academic organisations, he said.
Swaminathan has a rich experience over 30 years in clinical care and research. She most recently served as secretary of the department of health research in India and as director general of the Indian Council of Medical Research. Ellison was the UK’s public health minister from 2014 to 2016 and has worked in government, commerce and change management. Most recently, she was the special parliamentary adviser to the UK’s chancellor of the exchequer.
As before, Peter Salama will remain in his role as the executive director of the health emergencies programme.
A slew of appointments for assistant director generals was announced – Bernhard Schwartländer, chef de cabinet; Naoko Yamamoto, assistant director general for Universal Health Coverage and Health Systems Cluster; Lubna A. Al-Ansary, assistant director general for metrics and measurement; Svetlana Akselrod, assistant director general for non-communicable diseases and mental health; Michèle Boccoz, assistant director general for external relations; Ranieri Guerra, assistant director general for special initiatives; Ren Minghui, assistant director general for communicable diseases; Mariângela Batista Galvão Simão, assistant director general for drug access, vaccines and pharmaceuticals; Nothemba (Nono) Simelela, assistant director general for family, women, children and adolescents; Stewart Simonson, assistant director general for general management; and Joy St John, assistant director general for climate and other determinants of health.
There were speculations on how the new administration will delegate responsibilities and the extent to which there will be changes to parts of the organisation that may be restructured. There has been some discomfort on the lack of transparency on how his new team will be organised. It is not clear if this lack of transparency was strategic. But with the announcement of Tedros’s new team, there will now be more clarity.
After taking over from former DG Margaret Chan, who headed the WHO for ten years, Tedros put in place two kinds of teams to help him during the transition. The first is an informal group of internal and external experts who guided him on strategic issues facing the WHO and global health in general. “The membership of this group of advisers is not set but includes different advisers for different issues,” Gregory Härtl, spokesperson at the director general’s office at the WHO, told The Wire. Some of his key advisors have included Senait Fisseha, Peter A. Singer, Bernhard Schwartländer, Michel Jancloes and Joanne Carter, among others.
There is another team – a working group on the transition, advising him on “high-priority” changes within the organisation. This group drawn from existing WHO staff – a constituency that the DG wants to take along to implement his goals. Departments within the WHO usually work in silos and do not collaborate enough – something the new DG reportedly wants to change in order to be more effective. As before, the DG has leaned both on staff and external consultants, to advise him on the transition. The internal group comprising staff is headed by Elil Renganathan who heads the WHO’s evaluation office. The other members of the team are understood to be – Tim Armstrong , Andreas Mlitzke, Jean-Marie Okwo-Bele, Maria Neira, Marc Touitou, Agnès Soucat, Ruediger Krech, Mubashar Sheikh, Gottfried Hirnschall, Etienne Krug, Bente Mikkelsen, Peter Graaff , Jen Linkins, Shambhu Acharya and Françoise Nocquet, among others.
According to initial impressions of those who have also worked with other director generals, Tedros has been perceived as someone who is politically astute and knows what he is doing. His previous high profile political roles as foreign minister of Ethiopia put him in a different league, enabling him to reach out to leaders directly – which according to some, Chan was not able to do as much. His political leadership is crucial not only in pushing the objectives of the WHO beyond what the member-states want, but to also secure the place of the WHO and protect multilateralism in global health.
Tedros has spent time to meet officials and understand the organisation before jumping headlong to reform it in order to deliver on his campaign promises, observers say. “Unlike earlier, where there was one-way communication, Tedros is keen to listen to what staff have to say,” a global health expert familiar with the WHO told The Wire.
Citing his comfort and confidence in this role, one seasoned observer, formerly at the WHO told The Wire, that after assuming office, Tedros reportedly did not rush to reach out to regional directors himself, but waited for them to approach him. Irrespective of how he will deal with the regional offices at the WHO, Tedros will have to build on the global policy group constituted earlier – for better implementation and coordination of decisions, policies and strategies of the WHO across all its levels – the source added.
Whatever his strengths are, Tedros has to move quickly – for no leader will have time forever, commentators say. “Tedros and his team will have a very short window to push through their goals, whether it is reforms or other priorities, before they are overwhelmed by the system”, cautions a former WHO official who spoke on the condition of anonymity.
Schwartländer, the new chef de cabinet and who was formerly the WHO’s representative in China, is expected to have the required latitude to initiate reform within the institution and work closely with the DG. There is already reform-fatigue within the institution over the last few years and insiders say that it will be toughest to attack those departments that are run like fiefdoms within the WHO. “Some departments have enough powers and connections to influence the workings inside the institution,” one source said.
Tedros has already initiated processes and consultations on the priorities for the WHO for the coming years. The new programme of work for 2019-2023 (13th General Programme of Work [GPE]) – essentially priorities for the institution – will be taken up the annual EB meeting in January 2018. The board will then send it to the World Health Assembly in May 2018 for approval.
The WHO’s governance at the global level is carried out by the 194-member World Health Assembly and the 34-member EB and at the regional level through the WHO’s Regional Committee Meetings. The regional levels are informed by a range of technical and advisory committees that are convened under the aegis of the WHO.
The WHO has published “a conceptual framework for organising the WHO’s work and measuring its success.” It is now in the process of holding consultations at various regional levels. A special session of the EB will be conducted during 21-23 November 2017, dedicated solely to the GPE. The GPE will serve as the organising framework for two programme budgets between 2020-2023 and provide a strategic basis for resource mobilisation, according to note. (Special sessions of the EB are rare, but have been convened in the past including during the Ebola outbreak.)
In the note, there is a strong emphasis on measuring impact of the WHO – a shift from focusing on outcomes than merely on outputs. It remains to be seen what this shift will mean for measurement of impact and the financing of complex programmes where measurement may be difficult – a challenge also in the wider ecosystem of international development.
The WHO has to also strike a balance while prioritising the range of tasks that member-states demand of the organisation. There is more pressure on it to be operational, even as it works to strengthen normative and technical functions – most useful for developing countries. “WHO recognises that its normative function is a key source of strategic comparative advantage,” the organisation has said in the draft note.
In a speech at the meeting of the WHO’s African region, Tedros spoke of some his immediate priorities including measures to boost effectiveness in emergencies through daily briefings; measures to improve governance at the EB and to make the assembly more strategic; to rethink resource mobilisation; to pursue greater value for money in travel and other expenditures; to examine climate change in small-island nations among others.
The push for Universal Health Coverage (UHC) has increasingly got top attention during his campaign and since taking over. According to International Labor Organisation, only 60% of the people in the world have access to health care without financial hardship. According to estimates by the WHO and the World Bank, 400 million people do not have access to essential health services.
UHC is likely to remain front and centre during the tenure of Tedros who has described the access to healthcare as a human right and will continue to push member-states to work towards it. He has said, “Health systems are the glue that binds together all the priorities in the General Programme of Work. Universal health coverage is a political choice I urge countries to make.”
It has been estimated that health targets under the Sustainable Development Goals (SDGs) would require new investments upto $371 billion, or $58 per person, by 2030. Countries must take ownership of financing these targets and it has been estimated that 85% of these costs can be met with domestic resources. However, some of the world’s poorest countries will face an annual gap of up to $ 54 billion and will continue to need external assistance.
Locating the WHO’s responsibilities firmly in the context of the SDGs, Tedros has underscored preventing, detecting and responding to epidemics – as a key strategic priority. More people die from the consequences of natural disasters and conflicts – such as cholera or lack of access to essential health services – than from these events per se. Tedros has said that both are important – providing health services in emergencies and rebuilding health systems in fragile, conflict and vulnerable states.
Resource mobilisation and the role of country offices
These large responsibilities have to be financed. Resource mobilisation for the WHO has been a priority of the new DG but if and how he will accomplish will need to be seen. His connections and prior experience in global health including at The Global Fund to Fight AIDS, Malaria and Tuberculosis, and at GAVI, the immunisation agency will contribute to this objective.
During the last three months since assuming office, Tedros has travelled extensively to drum up support for his priorities and to meet leaders, including the G20 forum. In August he visited China for the Belt and Road Forum for Health Cooperation to discuss a “more strategic partnership between WHO and China”, and how China can expand its international health security cooperation along the Silk Road. “Universal health coverage and health security are the two sides of the same coin”, he has said.
China signed a memorandum of understanding with the WHO for an additional voluntary contribution of $ 20 million. Although this annual increase in contribution is modest amounting for less than $5 million over the next few years, it is nevertheless seen as China’s efforts to play a more serious role in global health and in the expanding security agenda. By contributing to the WHO, countries can leverage influence in global health experts believe.
One of the suggested strategies for resource mobilisation in the draft concept note includes elevating the political profile of country offices. Insiders say the choice of Schwartländer to play a more prominent role at the WHO can also be attributed to his success at the country office in China. Indeed, in its note, WHO talks about “…a new generation of WHO country representatives who are strong and effective health leaders and health diplomats. WHO needs its best people at the country level, particularly in the most challenging countries. WHO representatives will also become key partners in resource mobilisation for our work at the country level.”
This is also in line with his stated intention for greater decentralisation. During his campaign, Tedros had said that he would want country offices to be strengthened and priorities to be shaped in national capitals and not only at the headquarters in Geneva. The WHO has been having a series of annual regional meetings over the last few weeks. One indication of the seriousness of this intention can be seen in the number of senior officials from the headquarters who were slated to travel to the South East Asia Regional Office (SEARO) Committee meeting in Maldives in September 2017 – three times the number of officials compared to those in the previous administration under DG Chan for a similar meeting.
The WHO also wants countries to help raise finances for the organisation considering that they want it to play a stronger role. “Member states should raise funds for the WHO, and this should occur at a senior political level. The WHO will also improve the connection between these external relations functions and programmes, since initiatives like health for all are both political and technical….”, according to the draft note. One health expert in Geneva said that it is important for the WHO country offices to not only engage with ministries of health but also those of finance and trade.
WHO asked to take the lead on negotiating R&D treaty
Setting priorities is one task, but making resources available and finding the means to reach health targets is another. Countries like India, want the WHO to take the lead in negotiations for a new treaty on research and development. After all medicines for both communicable and non-communicable diseases are a major part of out of pocket expenses for patients and account for a large chunk of procurement costs for governments. The R&D efforts on new medicines must focus on diseases of the developing countries, India has said.
There are worries that Tedros is keen on making the WHO more operational, even as many countries seek normative guidance. Issues such as innovation and access to medicines are contentious and political but the WHO’s leadership on such matters is crucial.
There is optimism around the new administration at the WHO. The coming months will reveal if the new DG and his team will engage with the more challenging issues or will fight shy and preserve status quo.
(India’s Ministry of Health & Family Welfare, and the WHO’s SEARO is organising the “First World Conference on Access to Medical Products and International Laws for Trade and Health” from November 21-23, 2017 in New Delhi.)