The process for selecting the chief of the world’s biggest multilateral health organisation is underway. The next director-general (DG) of the World Health Organisation (WHO) will be elected at the world health assembly (WHA) in May as the current DG Margaret Chan steps down in June after ten years. Much has changed in the global health landscape during the past decade as new threats have emerged and old ones have quietened down. 

The process of selection unfolds thus: nominees of the governments were announced on September 23. The following month, the candidates interacted with member states through a web forum. For the first time, a live forum was held at the WHO headquarters in Geneva in November where the candidates presented their vision to the governments. The member states asked them questions during the 90 minutes allotted to each candidate. This is part of the UN secretary-general’s plan to bring in transparency in top appointments in the global body. Finally, the executive board will interview five of the six candidates in January and short-list the three whose names will be sent to the WHA. For the final selection, each candidate would have to make a short speech before the WHA. Member states would elect the next DG in a secret ballot and on a ‘one government, one vote’ basis. The new DG assumes office on July 1, 2017.

Currently, there are six candidates in the race: Tedros Adhanom Ghebreyesus (Ethiopia), Flavia Bustreo (Italy), Philippe Douste-Blazy (France), David Nabarro (UK), Sania Nishtar (Pakistan) and Miklós Szócska (Hungary).

Ghebreyesus, who has been endorsed by the African Union, is a former health and foreign minister of Ethiopia. Though he is not a WHO insider, Ghebreyesus, presumably, has much experience in dealing with failing health systems, and has also served in important positions in Gavi: The Vaccine Alliance and UNAIDS.

Bustreo is currently the assistant DG at the WHO for family, women’s and children’s health for six years. She has been the deputy director of Child Survival Partnership for UNICEF, incharge for India and Pakistan among other countries.

Douste-Blazy is a former university professor in medicine specialising in public health, epidemiology and preventive medicine and held key positions in the French politics. He is a former minister of culture and communication, health and social protection, and foreign affairs.

Notably, he was the chair of the executive board of UNITAID and brought prices of antiretrovirals down to $1 a day through successful partnerships. He is currently the under-secretary-general of the UN and special adviser to the SG on innovative financing for development. Because of his work on lowering drug prices and experience of working within the UN system, Douste-Blazy is a favourite of many health activists.

Nabarro too has vast experience in negotiating the WHO system. He has been special adviser to the SG on the 2030 sustainable development agenda and climate change, special representative of the SG for food security and nutrition, former chair of the advisory group for WHO’s reform in emergencies work, former special envoy of the SG on Ebola, former assistant SG for avian and human influenza, former head of WHO’s health emergencies group and the former executive director of the office of the DG. Nabarro has the backing of some developed countries and is a strong candidate.

Pakistani candidate Nishtar does not have as much experience within the UN’s health agency as Douste-Blazy and Nabarro but she has been a part of working groups and expert groups of the WHO. She has served as member of the DG’s working group on R&D and financing and DG’s high-level task force on health systems. The articulate cardiologist apparently enjoys support of some Islamic countries and started her campaign much earlier in the year. Pakistan had also nominated her for the post of the head of the UN’s refugee agency that was bagged by the Italian diplomat Filippo Grandi.

Hungarian doctor Szócska is a former minister of state for health and currently the director of a health management training centre in a university. He seems to have the least experience within the WHO system.

Challenges ahead

The challenges before the future DG are way too many – starting with the major credibility crisis that the UN health agency faces after the Ebola debacle – to draw up an exhaustive list. Some reforms are underway but it is too early to predict how those would turn out.
“WHO is facing questions about its identity and purpose. My first priority is to transform and make it more accountable,” Ghebreyesus told the WHO member states.

The lack of confidence in the system also emanates from the fact that there is a huge financial crunch in the WHO. A recent assessment reveals that if governments don’t chip in quickly then the WHO would finish the current biennium with a funding gap of $500 million – 15 percent of the budget. With a gap of 46 percent, the emergencies programme remains the most underfunded programme. This is despite the fact that the May 2016 WHA had agreed to increase the health budget of the emergencies programme by $160 million pushing up the WHO budget to $3,354 million.

The situation was dire enough for Chan to call an extraordinary meeting of the WHO on October 31 that saw participation of 72 governments and other stakeholders. Among other things, discussions on increasing the assessed contributions from governments were initiated ahead of the governing body meeting in 2017. Chan has appealed to governments to raise their assessed contributions by 10 percent. The WHO currently receives a total of US$929 million in assessed contributions. The proposal has evoked mixed reactions.

Apart from emergency work, a number of other programmes too have critical shortfalls in their budgets – response to antimicrobial resistance, work on non-communicable diseases and HIV, to name a few. Though polio eradication is good news for the world, the drying up of polio funds would have deleterious effects on the health systems of poorer countries. Core voluntary contributions to the WHO have decreased while voluntary contributions have remained the same.

WHO continues its long struggle with the budgetary imbalance between assessed and voluntary funding.

With the reluctance of governments to put in more money into the WHO, the contribution of corporations and foundations has substantially increased. Most of these funds come with strings attached, streamlined with priorities and politics in the form of pet projects. For instance, the Bill & Melinda Gates Foundation pours in money to help the Global Fund to Fight AIDS, Tuberculosis and Malaria. The core budget that needs to be replenished regularly and without subject to conditionalities finds itself dry. Added to that, many national governments themselves invest far less than the 6 percent of their GDP in their health systems that the WHO recommends them to do. This makes for a disastrous situation when emergencies like the Ebola virus strike and the WHO finds itself floundering.

If WHO would stop chasing funding from private parties after having achieved a robust core budget it could have more leeway in determining allocation of resources based on the recipient country’s needs rather the donor’s priorities.

After many rounds of loud negotiations, the WHO adopted the Framework of Engagement with non-State Actors (FENSA) resolution in this year’s WHA to prevent WHO from getting unduly influenced by donors in its normative and standard-setting core mandate. Though not all activists are happy with the adopted resolution, it’s a step in the right direction.

What candidates said

However, most candidates were careful in not ticking off the private sector. Apart from the WHO discussion, the candidates have interacted with an audience at a Chatham House discussion held on November 2.

“Sustainable Development Goals encourage us to engage with the private sector. We have been treating the private sector like pariahs for very long time. That mindset needs to change,” said Nishtar during a question and answer round.

Though undue influence from the private sector needs to be prevented by “creating firewalls”, it was necessary to engage them – it was not possible to get Ebola vaccines in a year unless the private sector joined in, said Bustreo.

Apart from this, the fact that many of the competent healthcare workers and physicians are hired by the wealthy nations for more lucrative jobs was an oft-raised issue at the meet. There has been a steady flow of nurses from China, India and Philippines to the developed world, for instance.

“Over the last five years, the government has lost 53 percent of its health administrators, 64 percent of its nurses, and 85 percent of its physicians – mostly to foreign NGOs, largely funded by the US or the British government or the Gates Foundation, which can easily outbid the ministry for the services of local health talent,” noted a Foreign Affairs article in 2007 titled ‘The Challenge of Global Health’. The situation remains the same today. Such drain has tremendous consequences for burdened health ministries. Many of the experts that the WHO hires remain posted in Geneva and not in the capitals where the expertise is needed. Both the questions of brain drain and decentralisation of resources were raised by member states, especially from the African nations, in the question and answer session of the candidates.

Less than 1 percent of the health workforce comprises nurses. The candidates have spoken nothing about the huge need for nutritionists, psychiatrists, etc. in the health workforce who are better distributed across the world, said an audience member in the Chatham House discussion.

Health is political and therefore could sometimes be an aggressively contentious terrain, sometimes. These issues, as is the case in other multilateral forums, are aligned along the North-South divide though the world we live in is much more multipolar than it used to be. So while the funds flow in from the North into the WHO coffers, majority of the poor and the diseased live in the South. Also, it is generally understood that the health security agenda is advanced on a war footing only when it threatens the West. Negotiating these fractures is a tall task for any DG. These were some of the issues thrown at the discussion.

“Notwithstanding your claim to be a candidate from a developing country, in my view, you have espoused an agenda that is very much aligned with the priorities of the North such as approaching global health through a security lens, treating universality through a concept of coverage not of a universal health system. You see WHO as an implementer of international health regulations, not as a standard-setting body. You focus on fragile states, hard-to-reach settings, but with very little clarity on WHO’s mission with respect to the development agenda. So, how can we translate your views in terms of a development candidate?” Brazil asked Ghebreyesus at the forum.

This North-South divide is most visible, for instance, in the discussion around SG’s UN High-Level Panel (HLP) on Access to Medicines report published on September 14. While the northern countries, especially the US, and pharmaceutical companies have strongly criticised the formation of the panel and its report, the lower and middle-income countries have been pushing for more strong action by the UN for enhancing access to cheaper drugs and vaccines and having an R&D convention.

“While we fully support the right of everyone to the enjoyment of highest attainable standard of physical and mental health... we cannot support the assertion... that creates a responsibility for states to ensure access to medicines, which is unfounded in law,” the UK had told the UN Human Rights Council in a recent session in the context of the UNHLP.

In fact, a recent request by India to the forthcoming WHO Executive Board (EB) in 2017 to include a discussion on the UNHLP was rejected. (India, along with Brazil, China and South Africa requested WTO’s TRIPS Council to hold a dedicated session of the report on November 8 and 9, which was accepted by WTO.)

“Despite the great strides achieved in the prevention, diagnostics and treatment of diseases, developing countries are still excluded from many of the benefits of modern science. What concrete proposals do you have to address this issue and public health, innovation, intellectual property and trade involving WHO, WTO and WIPO?” Colombia asked Nishtar at the WHO forum.

At this point, the US ambassador to the UN Pamela Hamamoto (a classmate of president Barack Obama) took her earpiece to listen to
Colombia’s question. Leaked documents had revealed that the Colombian officials feared that the US funding for the Colombian peace process might suffer if Colombia side-steps a patent on Novartis’s cancer drug.

“What out-of-the-box thinking in terms of health related SDGs and specific priorities in this regard are you bringing to the table?” India asked Dr Ghebreyesus.

While British candidate Nabarro did not touch much upon the UNHLP on access to medicines during the discussions at WHO, he answered a question from the audience in the Chatham House discussion that he would address North-South issues from a “moral and ethical” position, and that changes in intellectual property rules alone are not enough – a lot more has to be done. 

An audience member complained that the candidates had talked “very blandly about universal health coverage and nothing about accessibility”. “We need to have guidance [from WHO],” she said citing the cases of poor countries like Sierra Leone.

“How will the DG deal with discrimination in access to health based on the gender identity of the person,” a European country asked Italian candidate Bustreo, presumably to understand her political views on alternative sexual identities. We have to understand what kind of discrimination is hampering health, Bustreo said. “This is not the Human Rights Council” though we work with them but we are not that. There is a need for evidence that discrimination is actually hampering access to health, she added.

“How will you convince governments to invest more in health systems? How do we enhance health as priority for the world?” asked a lady from the audience.

“How will you handle issues of religious beliefs in implementation of health policies?” asked an economist.

“You have talked a lot about words and acronyms but please give some technical answers that could move things forward so our children don’t have to face the same problems of infectious diseases and other public health concerns that we have been facing for 36 years,” said a midwife nurse from the University of Westminster.

Clearly, the expectations run high; the future DG’s plate is more than full for a term and beyond.

shreerupa@gmail.com

(The article appears in the November 16-30, 2016 issue)