The World Health Organization’s 194 member states will this week elect the next director-general of the global health agency at the 70th World Health Assembly, the agency’s annual general meeting, which begins tomorrow in Geneva, Switzerland.
One of the three candidates shortlisted by the Executive Board on January 25 will emerge as the eighth director-general of the agency to succeed Margaret Chan whose second term of office ends June 30.
It will be the first time the director-general will be elected by the WHO’s member states. Before now the member states accepted a backroom choice by the Executive Board.
It has been a long and highly political process. Last September, six candidates were nominated for the position by the WHO member states – four Europeans, one African, and one South Asian.
Out of this list, Ethiopia’s Tedros Adhanom Ghebreyesus (mostly known by his first name), Pakistan’s Sania Nishtar, and Britain’s David Nabarro made the final shortlist.
Italy’s Flavia Bustreo, a WHO assistant director-general, and France’s Philippe Douste-Blazy were knocked out at the January 25 voting. Miklós Szócska of Hungary had been dropped earlier on January 24 to bring the number of contenders to five.
Who the cap fits
In an October 2016 article “How to choose the world’s top health diplomat”, Ilona Kickbusch of Global Health Centre, Graduate Institute for International and Development Studies in Geneva, and colleagues Ngaire Woods of Blavatnik School of Government and Director of the Global Economic Governance Programme, University of Oxford, Peter Piot of London School of Hygiene and Tropical Medicine, and Kamran Abbasi of The BMJ, London, discussed the qualities required for the next WHO director-general, “one of the world’s most critical appointments”.
Kickbusch et al contended that while WHO has outlined selection criteria, the position is ultimately a political one.
“Technical excellence in public health is only part of the requirement, although it does provide additional credibility and insight for decision making,” they said.
Quoting Resolution WHA65.152, they stated that the candidates nominated by the board should fulfil certain criteria, while underscoring the paramount importance of professional qualifications and integrity and the need to pay due regard to equitable geographical representation, as well as gender balance.
These criteria include “a strong technical background in a health field, including experience in public health; exposure to, and extensive experience in, international health; demonstrable leadership skills and experience; excellent communication and advocacy skills; demonstrable competence in organisational management; sensitivity to cultural, social, and political difference; strong commitment to the mission and objectives of WHO; good health conditions required of all staff members of the organisation; sufficient skill in at least one of the official working languages of the Executive Board and the Health Assembly”.
For and against Nabarro
Some experts say 67-year-old David Nabarro is easily the most qualified for the top WHO job on grounds of experience.
Nabarro, who studied at University of Oxford and University of London and qualified as a physician in 1973, has spent much of his career in the WHO and the United Nations, his latest posting being as special adviser to the UN secretary-general on sustainable development and climate change.
Nabarro also sees himself as cut out for the job.
“As somebody who’s worked in more than 50 countries, and quite intensively in 15 of them, I feel it’s a job I’ve been training for all my life,” he said in a recent interview.
Nabarro is pitching himself as a physician-diplomat who has become the go-to guy for sorting out the world’s public health screw-ups — not as the “British” candidate, said Sarah Wheaton, senior health reporter for POLITICO, in a recent article.
However, he’s clearly the UK candidate. On October 21 last year, the UK government gave its formal backing to Nabarro and is devoting resources to his WHO bid, providing him with staff and cash.
“The U.K.’s Conservative government is making sure Nabarro has a proper campaign against his rivals from Ethiopia and Pakistan,” Wheaton wrote.
Andrew Mitchell, a Conservative MP and former head of the Department for International Development (DfID), who is rooting for Tedros, said Nabarro “is the British candidate and he has the support of the British government”.
Nabarro himself has acknowledged he has the active support of the British government in a May 12 tweet via his Twitter handle @davidnabarro.
“Appreciative of UK Govt support. I’ve always been, and will continue to be, transparent. My campaign finances,” he tweeted.
According to a financial disclosure quoted by Wheaton, the U.K. poured the equivalent of €72,000 through March into Nabarro’s breakneck jet-setting to more than 40 countries to make his case to health officials, foreign ministers and civil society leaders.
“His Twitter timeline includes visits to Fiji, Barbados and Oman. (Like the other candidates, he has also spent ample time in South America, seen as up-for-grabs in the geopolitical game.),” said Wheaton.
Nabarro also has three full-time staff devoted to his campaign in the U.K.’s Foreign Office and enjoys the support of powerhouse PR chief Richard Edelman, as well as the global political capital of Sally Davies, U.K.’s Chief Medical Officer.
Davies and other supporters point to Nabarro’s experience as the point-man in the WHO’s Ebola post-mortem, the UN’s effort to treat the cholera epidemic its own troops brought to Haiti and Turtle Bay’s response to pandemic flu.
Some pundits believe that Britain’s strong advocacy power and its foreign-aid footprint (devoting 0.7 percent of its GDP to foreign aid) may count in Nabarro’s favour.
Britain “is the third-largest donor to the WHO – second if you don’t count Bill Gates”, said Natalie Huet and Carmen Paun, both of POLITICO, in a recent article.
But outside Europe, Nabarro is viewed as the European in the race. While some observers think this doesn’t exactly count in his favour at the moment, given the word making the round that it is Africa’s turn, others think that as the only European left, Nabarro’s chances may have been raised. At the January 25 voting, the presence of multiple Europeans on the ballot was seen as capable of splitting what would otherwise have been a significant bloc.
Even Britain’s departure from the European Union was – and still is – viewed as a minus for Nabarro.
“The increasingly acrimonious Brexit negotiations mean Europe is not particularly poised to cooperate with its future ex,” Wheaton said.
The Financial Times reckons that the recent appointment of DfID chief Mark Lowcock to head the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) by Secretary-General António Guterres “could complicate David Nabarro’s bid for the WHO”.
Nishtar’s chances
Sania Nishtar, 53, is the sole female candidate in the race. She holds a Fellowship of the Royal College of Physicians and a PhD from King’s College London. An entry on her on www.who.int says Nishtar is the founder and president of Heartfile, which began in Pakistan in 1999 as a health information-focused nongovernmental organization and evolved into a think-tank on health policy issues. She is also founder of Heartfile Health Financing, a programme that uses a customized IT platform and mobile phones to protect poor patients from medical impoverishment or foregoing health care.
On the global stage, Nishtar has been involved with many international agencies in various capacities, including the WHO, the Alliance for Health Policy and Systems Research, the Global Agenda Council of the World Economic Forum, the Health Global Challenge initiative, among others. She is acclaimed to have extensive experience both nationally and internationally in the civil society sector.
Like her UK counterpart, Nishtar is also getting some government help, although her campaigns are run almost exclusively by volunteers. The Pakistani government bankrolled €128,000 of Nishtar’s travel and several receptions over the past year, and Pakistani diplomats on the ground in foreign countries are helping set up her meetings.
Odds favour Tedros
In his vision statement, 51-year-old Tedros Ghebreyesus, the only non-physician among the candidates, says he envisions a world in which everyone can lead healthy and productive lives, regardless of who they are or where they live.
Many pundits believe that the odds favour Ghebreyesus, the African candidate, who has the support of the African Union, potentially a bloc of 54 votes at the World Health Assembly.
The word in international circles for a while has been that it is Africa’s turn. No African has led the agency in its almost 70-year history. A number of potential African candidates tested the waters early on but did not go far. With the sole African candidate now in the final voting stage, optimism on his possible success is on the rise.
“There’s a strong sense that it’s Africa’s turn to lead the U.N. agency after the WHO’s flat-footed response to the Ebola crisis in West Africa. Ethiopian candidate Dr. Tedros Adhanom Ghebreyesus is getting overt support from his continent, with the African Union formally endorsing him last year,” said Wheaton.
In the months leading up to May, Tedros has garnered endorsements from across the globe. Peter A. Singer, chief executive officer of Grand Challenges Canada, and Jill W. Sheffield, an independent consultant and long-time advocate for women’s health and rights, endorsed him in a joint Op-ed, as did Prashant Yadav, a senior fellow at the William Davidson Institute at the University of Michigan and a visiting scholar at the Harvard Medical School, and Akash Goel, a physician, journalist, and a World Economic Forum Global Shaper.
Former DfID chief Mitchell, as well as Nicole Schiegg, former senior advisor of USAID currently working as an independent consultant of global development, have also recently endorsed him.
“Electing Dr. Tedros is the best way to ensure better health for all the world’s people,” Schiegg said in a recent article
published in Huffpost.
She added that while the other two candidates in the race are accomplished, Dr Tedros Adhanom of Ethiopia is the best choice [and] more qualified to lead WHO at this pivotal moment.
Also endorsing Tedros in a recent Oped in the Guardian (UK), Mitchell cited his record of overhauling other global health groups, his fundraising prowess and his background.
“In its 70-year history the World Health Organization has never been led by a person who has been a health minister, or a person from Africa,” Mitchell wrote, adding that “by convention”, permanent members of the UN Security Council “do not supply heads of such agencies”.
But POLITICO notes that this “convention is not ironclad: The head of the UNICEF is from the U.S., and a Brit has run the UN Development Program in the past.”
While Singer and Sheffield argue that Tedros’ kind of experience and expertise is precisely what “the WHO needs in today’s global health environment”, Yadav and Goel reckon that his suitability is his irrefutable ability to create and build efficient and sustainable health systems, the linchpin of health-care delivery, arguing that under his leadership, Ethiopia made such dramatic improvements in public health outcomes that are often heralded as a model for health-care delivery in low- and middle-income countries.
“The WHO urgently needs a leader to repair its deficit in finances and credibility. Fractured and under-resourced health systems are in need of fortification to not only protect those within their own borders but also to build resilience against the rise of transnational threats to public health. Tedros is the candidate to do both, and it would be in all of our best interest to elect him,” said Yadav and Goel.
Tedros holds a PhD in Community Health from the University of Nottingham and has for over three decades been a distinguished leader who has saved and improved lives in Africa and around the world. A globally recognised expert and author on health issues, including health workforce strengthening, emergency responses to epidemics, and malaria, he has been co-chair, Partnership for Maternal, Newborn and Child Health Board, chair, Roll Back Malaria Partnership Board, chair, Global Fund to Fights AIDS, Tuberculosis and Malaria Board, Ethiopia’s minister of health as well as minister of foreign affairs. His reforms as health minister are said to have transformed Ethiopia’s health system to expand quality care and access to tens of millions of Ethiopians, while in the global context he helped key global actors like The Global Fund and the Roll Back Malaria Partnership operate with greater efficiency and effectiveness.
Whoever wins, the task ahead is arduous
While many pundits think Tedros is the best candidate for the job, credentials alone may not necessarily determine voting decisions as voting for a position like this involves backroom diplomacy and, often, horse-trading.
“I would be highly skeptical that that is the driving force behind voting decisions. I think countries will vote based on strategic calculations,” said Suerie Moon, director of research at the Global Health Center, Graduate Institute of International and Development Studies in Geneva.
But whoever wins, the task ahead is an arduous one.
Ed Whiting, director of policy and chief of staff at Wellcome, an independent global charitable foundation, has outlined several qualities the new director-general needs to have as well as actions the WHO must take to recapture the world’s confidence.
The WHO has faced a barrage of criticisms recently, especially following its slow response to the massive outbreak of Ebola in West Africa in 2014. There have since been calls for an overhaul of the agency, with particular emphasis on its emergency response capacity.
Whiting admits that despite its remarkable achievements, the WHO today is not fulfilling its mission, isn’t adequately funded for it, and is failing in its current form, but the arrival of a new director-general this month offers an opportunity for reform that the agency must put to good use.
He reckons that the WHO, as the only organization charged exclusively with speaking for public health and for health care workers around the world, needs more effective political leadership at this time to regain trust.
“At a time when health budgets around the world are under increasing pressure, the new director-general must strengthen the case for investing in improving health outcomes. That includes encouraging greater investment in stronger national health systems and epidemic preparedness, and being fearless in calling out countries that fail to take action where it is needed,” says Whiting.
The WHO, he says, must also strengthen its unique role in alerting the world to health emergencies and coordinating the responses to them. And while the WHO’s new emergencies team has shown that it can mobilize resources and action at a pace never seen in the organization’s history, the new DG, he says, needs to convince national leaders that the world doesn’t yet have the capability to respond to cross-border emergencies, making sure the WHO clearly sees the existing gaps and the steps needed to close them.
“The new director-general should also be fearless in calling out global health risks, such as the growth of artemisinin-resistant malaria in Southeast Asia, particularly where national and regional authorities are not doing enough to combat such threats,” he says.
He adds that the WHO must also lead the fight for access to innovative health care for all. The new DG will need to work effectively with “the increasingly mixed economy of health care funders and providers” to ensure that the WHO has sufficient funds for its mission, as well as make a greater effort to better develop the WHO’s relationships with civic society and the private sector as every dollar invested by private companies reduces the burden on finance ministries and taxpayers and also delivers innovations and technical advances that can improve health.
Whiting advocates an ambitious internal reform programme that simplifies the WHO’s complex governance structures, and challenging poor-performing offices at the national, regional, and global levels, contending that key to that would be ensuring that staff are selected for posts based on their competence, not their politics.
“Clear, decisive leadership on all of the above will go a long way to restoring confidence in the WHO — a vital prerequisite to attracting the financial support the organization so desperately needs,” he writes.
CHUKS OLUIGBO
