[Ip-health] Governance Now: Tedros becomes the first African to head WHO

Thiru Balasubramaniam thiru at keionline.org
Mon May 29 12:30:27 PDT 2017

Tedros becomes the first African to head WHO

Winning the election may have been the easier task compared to what awaits
the new DG

Shreerupa Mitra-Jha | May 29, 2017 | Geneva

#WHA70   #Dr Tedros   #Tedros Adhanom Ghebreyesus   #World Health
Organisation   #WHO director general   #Letter from Europe

“Call me Tedros,” the newly elected director-general (DG) of the World
Health Organisation (WHO), Dr Tedros Adhanom Ghebreyesus, told a Chinese
reporter at a press conference held after he was elected on May 23. “The
issue is: in Ethiopia we don’t have surnames, and also my wife or my
partner doesn’t take my name,” he said explaining why he ran his campaign
for the post of the DG with ‘Dr Tedros’ instead of using his surname.

A new beginning

Tedros became the first African to head the UN’s health agency in its
69-year-old history. He was selected after a tense election that ran into
three rounds defeating British candidate and former special envoy of the
secretary-general on Ebola David Nabarro and former Pakistani health
minister Sania Nishtar.

The World Health Assembly (WHA) this time saw two firsts: the first time
that an African became the head of the globe’s biggest public health agency
and also the first time that there was an election to choose the DG through
a secret ballot.

Previously, the all-powerful executive board (EB) of the WHO – comprising
34 member states elected for the tenure of three years each – made the
decision in closed-door meetings and pushed it forward to a mere rubber
stamping by the rest of the members. This had led to all sorts of
allegations being levelled against the UN agency. In a bid to bring about
some measure of transparency – though critics have said that this is not
enough – in selecting for this crucial position it was decided that large
and small governments alike could choose their candidate through a
one-country-one-vote system. But before that, the candidates – of which
there were six initially – had to face intense public scrutiny through
interactions between them and voting governments that were webcast

The names of candidates for the next DG nominated by member states were
announced on September 23 last year with French candidate Philippe
Douste-Blazy, Italian Flavia Bustreo, former Hungarian health minister
Miklós Szócska, Ethiopian Tedros Adhanom Ghebreyesus, Nabarro and Nishtar
making it to the coveted list. In October 2016, these candidates were given
the opportunity to interact with governments in a password-protected web
forum hosted by WHO. On November 1 and 2, 2016, a live forum was held, at
which candidates presented their vision and answered questions related to
their candidacy – this was live webcast.

In January 2017, the EB drew up a short list of five candidates, which
after interviews was winnowed down to three, pushing these names for the
final elections at the 70th WHA.

There was rigorous campaigning for more than a year with contenders
crisscrossing the globe for garnering support. Nabarro declared meeting
more than 100 health ministers while Nishtar travelled on a near-impossible
mission to New Delhi to ask for their support for her candidature.

“As you have heard before, while WHO has never had a director-general from
Africa, no one should elect me because I am from Africa but if you agree
there is real value in electing a leader who has worked in one of the
toughest environments and transformed the health system, who can bring a
fresh perspective, an angle with which the world has never seen before,”
Tedros said in a speech to the WHA at a plenary session just before the
election the evening of May 23. However, Tedros did have the support of the
African Union (AU), counting for quite a number of votes, because he is an
African as well as the support of the Pacific and Caribbean countries.
After his victory, Ethiopia’s permanent representative to the UN in Geneva
Negash Kebret Botora said, “It’s a victory day for Ethiopia and for
Africa.” Ethiopians, and others from Africa, were seen rejoicing near the
Broken Chair monument outside the Palais des Nations.

It is not certain how Indian health minister JP Nadda, who was leading the
Indian delegation at the WHA, pressed the vote button. But one can probably
make a fair guess. It is highly improbable that India would vote for
Pakistan – given the terrible relation between the two neighbours at the
moment – for heading a UN agency that peddles such huge influence globally.
It is also improbable, though to a lesser degree, that Nadda would have
voted for Nabarro who was not as vocal with his support for the
controversial report of the UN High-Level Panel on Access to Medicines
(UNHLP), the findings of which India vociferously supports and western
countries like the UK and the US denounce. Tedros was more supportive both
of the UNHLP findings as well as countries using compulsory licensing to
produce more generic medicines (though Nishtar was the most vocal of the
three on these issues).

In the first round of contest among the three final candidates, Tedros got
95 votes, while Nabarro got 52 votes and Nishtar had 38 votes. Since Tedros
did not get a clear two-third majority, the two candidates with the highest
votes got pushed to the second round while Nishtar dropped off the list.

In the second round, Tedros got 121 votes – just one vote short of the
two-third majority required – while Nabarro got 62 votes, requiring a third
round of voting where only a simple majority was enough to clinch the deal.
Tedros got 133 votes – though only 98 were required – finally defeating

Tedros’s campaigning, however, was marred by heavy media attention, many a
time negative highlighting his government’s role in human rights
violations. “I like his demeanor & many of his priorities. But I don’t
think the Ethiopian HR issue will just magically go away now that he’s DG,”
tweeted Kristof Decoster from the Institute of Tropical Medicines and the
editor of International Health Policies (IHP) newsletter. Before the
elections, the New York Times ran a story that alleged that Tedros had
covered up cholera outbreaks in Ethiopia by reporting them to the WHO as
“acute watery diarrhoea”.

However, Tedros found support from an unlikely source in Dr Tom Frieden,
the former director of the Centers for Disease Control and Prevention and
the US representative at the WHO EB meeting in January that chose the final
three candidates, who argued that many countries choose to report cholera
to the WHO as “acute watery diarrhoea” – something that can be reported
without laboratory confirmation.

Also, during the opening plenary, a freak incident of a man shouting
slogans against Tedros, before eventually being escorted out by the
security, startled the audience. But Tedros won. And won decisively.

WHO’s influence

WHO is more important to our everyday lives than what it is given credit
for. As such, there is a scramble for whose influence digs in the most
given the UN agency’s wide-ranging mandate  encompassing a plethora of
stakeholders. From Nestle and Pepsi to tobacco company Philip Morris to
Novartis and Cipla to governments, civil societies and the common person –
all have a stake in the policies of the WHO. It is supposed to raise the
alarm and guide governments through pandemics, direct governments on which
essential medicines to keep in its stockpile, pre-qualifying medicines,
recommending nutrition and dietary requirements, labelling carcinogenic
substances, deciding which vaccines are recommended for infants, children
and women, deciding which ailments are priorities to be tackled by
governments, restricting how tobacco companies sell their products, among
other responsibilities. It also helps other UN agencies and public health
bodies procure pharmaceutical products worth billions by making producers
and products go through a rigorous vetting procedure.

Just the beginning

Tedros, 52, who was the only non-medical doctor among the three candidates
may soon discover that winning the election was perhaps one of the easier
tasks compared to the challenges he may face in his five-year tenure, not
least of which is drumming-up support for the grossly underfunded agency
with its $4.4 billion budget.

WHA70 approved WHO’s programme budget for $4,421.5 million for the
biennium, including a 3 percent ($23.2 million) increase in governments’
assessed contributions for 2018-19. Assessed contributions form the core
budget of the WHO, which is then free to allocate resources according to
its priorities as opposed to voluntary contributions from governments and
private companies, which earmark their money for specific causes, like the
Gates Foundation contributing for polio work. Though the assessed
contribution has increased after a long time, it is nearly not enough for
the WHO to function smoothly.

“So, the campaign has ended, as you know, officially, but I think more work
begins, actually, now. And I know it’s very difficult. It’s going to be
tough. It’s not going to be easy,” Tedros said in his first press
conference after the election.

To add to the global agency’s dire straits, the Donald Trump administration
has been increasingly dodgy in funding multilateral agencies given the US
president’s apathy towards money trickling out of America into the coffers
of inter-governmental bodies.

The US administration has issued an outline budget which has called for
deep cuts in some of the global health agencies worldwide, as well as peace
keeping,  climate change, and other international bodies.

The announced cut to US aid is 32 percent, to global health is about 17
percent and to scientific research institutes between 20 and 30 percent.
What are the DG’s concerns going into his position for funding of the WHO,
a Reuters correspondent in Geneva asked.

“One the budget issue, I think it’s very important to move really fast in
really addressing the budget issue. And when we talk about budget issue,
most of the time we raise the WHO budget only.

“But that’s not the right way of thinking about financing Global Health
Agenda,” Tedros responded. He then spoke of a  “bigger envelope” and
diversifying the donor pool, of financing global health through the World
Bank, Gavi and The Global Fund, creating a special office for funding like
at the UN’s child agency and becoming less dependent on traditional donors.

“But how in the world are you going to close a $2.2 billion gap, and
whatever billions it turns out to be is lost with the United States leaving
the field?” gasped another American journalist.

The answer was fuzzy.

“I’m a strong believer that there should be an exit strategy. Means gradual
exit that avoids any shocks. Because when there is finance cut like this,
the most affected are the poor, by the way,” Tedros replied and added there
was a need for increasing assessed contributions.

“While campaigning, I have been talking to some countries and willing to
contribute, like what the US, UK and other countries do. You know, the
voluntary contribution? There are countries who are willing to contribute,”
the new DG said. But voluntary contributions, as mentioned before, bind the
WHO to the donating government’s or private company’s priorities rather
than the money being aligned to WHO’s priorities. “WHO’s own capacity to
support national health systems remains weak despite their centrality, with
most resources earmarked for specific diseases or programmes,” said a
Lancet report.

This was one of the many reasons for the debacle in WHO’s response to the
Ebola crisis in Africa in 2014. The agency did not have enough money for
preparing for emergency responses that came from assessed contributions.
Nor was there a clear response from the DG on how he will convince
governments to put in more money into WHO’s core budget.

Additionally, it is detrimental to WHO’s cause of shoring up resources with
the fact that it sometimes spends more on travel and hotel bills than
fighting widespread life-threatening ailments. Associated Press recently
reported that former DG Dr Margaret Chan had a $3,70,000 travel bill in one
year, and recently stayed in a $1,008-a-night hotel in Guinea. It used $200
million a year on travel costs with its officials flying business class and
staying in five-star hotels – and that adds up to more than it has reserved
for fighting global health crises, added the report.

The annual travel cost is more than what WHO spent last year in combatting
AIDS, hepatitis, malaria and tuberculosis, combined.

“WHO is nevertheless asking for more moolah to fight disease – and
taxpayers will be footing the bill,” screamed a New York Post report.

“Does it seem a bit misplaced that WHO staffers are able to travel business
class when they are actually working for the poor?” asked another
journalist to Tedros.

While “reducing the overhead cost as much as possible is important… but
when it comes to the travel cost, by the way, it has to be seen in relation
to the programme, because any travel expenses or other costs, as long as
they can be justified because of the programme, it’s fine,” Tedros said.

Implementing universal health coverage (UHC), including enhanced access to
medicines and vaccines, will be one of the major challenges though the DG
has called it the “centre of gravity” for his proposed work during his

“All roads lead to universal coverage. This will be my central priority,”
Tedros said to the WHA plenary before his election.

“At present, only about a half of the world’s people have access to health
care without impoverishment. This needs to improve dramatically,” he added.
Implementing UHC globally has been a priority area for the WHO since its
creation in 1948, but there is a long way to go before that is achieved.

Countries currently pursuing neoliberal economic policies, including India,
are definitely neglecting health on a large scale, said an Indian
journalist adding that health budgets are going down. The DG suggested that
the WHO should not interfere, intervene and interfere in this since this is
the government’s discretion. “Don’t you recognise that there is a
responsibility as the head of the WHO to intervene in this debate? To say
that public health investments have to keep up with the kind of disease
burden that is growing in these countries?” the journalist asked.

“As long as we agree on the goal, any government agrees on, you know,
achieving universal health coverage, the means could be private, public, or
a mix,” Tedros responded adding that WHO should advocate the outcomes not
the means.

“To secure medicines, the Director-General should champion the UN
High-Level Panel on Access to Medicines’ recommendations. Furthermore,
universal health coverage requires health workers…,” the Lancet report said.

However, implementing the findings of UNHLP will be a tricky terrain given
the acrimony of some of the biggest donors to the WHO towards the report.
The recommendations aim to close the gap between health innovation and
access and a call to double the funding for R&D to US$6 billion per year.

The pressure of drug companies to maintain high prices was most recently
exemplified during a resolution on cancer drug pricing that health
activists have said was considerably “watered down”.

“Under pressure from drug companies to avoid controversy this week,
negotiators eliminated text that called upon the WHO [to] do a feasibility
study of ending monopolies on cancer drugs, and addressing transparency of
drug prices, R&D costs and access gaps,” James Love, director of Knowledge
Ecology International, said at a press conference during the ongoing WHA

“But what remains does give the new DG, Dr Tedros Adhanom Ghebreyesus, a
sufficient mandate to do all of this, and the issue of de-linkage for
cancer drugs is being taken more seriously,” Love said.

The fact that DGs can run for a second term – carrying the obligation to
keep all governments, and in particular the more powerful ones, happy – may
act as an informal constraint on the choices that a WHO chief makes during
his or her tenure. Perhaps, it is time to consider whether rules should be
changed to restrict a WHO chief to only one term in the interest of better
global public health. The former Ethiopian health minister has an
impressive track record in working with flailing health systems and
especially in combatting AIDS, malaria and tuberculosis in his country. One
hopes that the informal pressures cited above do not affect his choices
that affect the lives of millions of the global poor.

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