[Ip-health] Devex: Election sees WHO's future role in question

Thiru Balasubramaniam thiru at keionline.org
Sat Jan 14 02:15:36 PST 2017




Election sees WHO's future role in question

By Sam Loewenberg 12 January 2017

When Jean-Bosco Ndihokubwayo reported back to headquarters in April 2014,
the World Health Organization Ebola expert did the electronic equivalent of
shouting. “WE NEED SUPPORT,” he wrote in the subject line of an email to
Geneva describing a ballooning epidemic at a major public hospital in the
Guinean capital of Conakry. The Ebola cases there were “the tip of an
iceberg,” as the health care workers themselves threatened to become
vectors spreading the disease, he warned in the email, later obtained by
the Associated Press.

Ndihokubwayo’s message was the latest of many warnings that the epidemic
was spreading. Ebola was new to the region, had reached urban centers, and
was overwhelming already weak health systems.

It would be another four months before WHO declared Ebola an emergency, at
which point the crisis was out of control. Despite increasing evidence of
the disease’s rapid cross-border spread, the organization waffled, as the
AP emails and other subsequent reports have shown.

Even as Ebola proliferated along the porous borders of West Africa into
Liberia and Sierra Leone, the heads of the agency’s infectious diseases
unit urged WHO Director-General Margaret Chan not to sound the alarm.
Declaring the Ebola outbreak a public health emergency of international
concern or even to bring together an expert committee, “could be seen as a
hostile act” by the affected countries and limit cooperation, a senior WHO
official urged in a June memo. Meanwhile on the ground, supplies and
expertise were severely lacking. Patients were turned away from overwhelmed
clinics and health workers did their jobs with insufficient protective

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Ultimately, the Ebola virus took more than 11,000 lives and threw millions
more into catastrophic circumstances. And while there is plenty of blame to
pass around, much of it fell on WHO — the one organization with the power
to declare an international health emergency and the mandate to coordinate
countries, NGOs and professionals across public health. In the eyes of many
who serve it, analyze it and pay its dues, the West African Ebola crisis
exposed WHO as an agency badly in need of repair.

“There was a major disaster waiting to happen at WHO, of course it did
happen with Ebola, but it could have been something else,” said Lawrence
Gostin, university professor at Georgetown and the director of the World
Health Organization Collaborating Center on Public Health Law and Human

The struggling agency will elect a new director-general in May 2017, the
first time the vote is open to the organization's entire 194 country
membership instead of just the executive board.

Ultimately, who leads WHO will have a consequential impact not just on the
organization but on all of global health. At the same time, the incoming
director-general will face significant constraints on her or his ability to
reform the agency, which has both a notoriously sclerotic bureaucracy and a
budget that is too small for its global mandate and overwhelmed with

In interviews with Devex, over a dozen current and former senior officials
from WHO, the U.S. and other governments, and global health experts
discussed how the organization has lost ground in global health, needs to
regain its leadership position and must strengthen its reputation and
independence. In many ways, WHO’s lackluster performance during the Ebola
crisis was symptomatic of many of its core struggles with governance,
including the leadership disconnect between Geneva and the regional and
country offices; its strangled budget and relative paucity of resources;
and the precarious balance between member state politics and the global
public good.

Six candidates are standing for director-general and Devex will publish
extended Q&As with each over the next week: Dr. Flavia Bustreo, Italy’s
candidate, currently on leave from her job as WHO’s assistant
director-general for family, women's and children's health; Dr. Philippe
Douste-Blazy, former French minister of health and of foreign affairs and
special adviser to the United Nations director-general; Dr. Tedros Adhanom
Ghebreyesus, former health and foreign minister of Ethiopia; Dr. David
Nabarro, senior U.N. adviser on health and environment issues who was in
charge of the Ebola response; Dr. Sania Nishtar of Pakistan, a former
government minister who led the reform of her country's ministry of health;
and Dr. Miklós Szócska, the former Hungarian minister of state for health.

Many of the candidates’ campaign promises so far echo similar themes:
improving WHO’s capabilities, transparency, coordination and funding.
Leadership, however, is the common thread. Whoever wins must be the public
face of the organization — the doctor to the world — while also mastering
the three-dimensional chess of U.N. politics. They must raise money from
demanding donors, placate and push member states, and manage both global
health experts and career bureaucrats spread throughout the world.

That sort of leadership — or some would say the lack thereof — fed directly
into the Ebola crisis. “Ebola brought under the spotlight some of the
weaknesses of international health governance, and WHO was at the heart of
it,” said Dr. Joanne Liu, international president of Médecins Sans
Frontières, which heavily criticized the WHO for waiting months before
declaring Ebola an international emergency. “We need strong leadership,”
she said.

Every year, the World Health Assembly takes place in the Palais de Nations
in Geneva, Switzerland. At the 70th World Health Assembly on May 22-27,
2017, member states will vote in a new director-general. Photo by: Violaine
Martin / WHO

Part one

Looming over the WHO election is the existential question of what the
organization should really even be — what it should do, how, with what
authority, and on who’s dime. Answering that quandary will involve as much
politics as philosophy.

Many people envision WHO in its Hollywood portrayal: first responders in
moon suits, arriving in helicopters to put down the latest infectious
disease outbreak in an uncharted corner of the globe. In truth, much of
WHO's work happens in drab conference rooms. It is first and foremost a
standards setting and guidelines agency that convenes experts to set global
health norms. WHO is normally a slow-moving bureaucracy, but when disaster
strikes, it is expected to jump in and help coordinate the response from a
multitude of public health actors.

Over the years, WHO’s mandate has grown as member states’ needs have
evolved. Many of the organization’s priorities must now compete for limited
resources and staff. Some of the most difficult issues mirror political
fault lines between the “global north” and “global south,” such as
intellectual property for pharmaceuticals and health worker migration;
while others matter for both hemispheres, such as the growth in
noncommunicable diseases and efforts to curb the marketing of unhealthy
foods high in sugar, salt and fat. In the aftermath of Ebola, rich
countries such as the United States want to see WHO more focused on
emergency response to pandemics, while less-developed countries value the
organization’s support to strengthen core health systems.

These days, WHO operates in a world populated by a plethora of other
players, many of which are better funded, more focused, and sometimes more
effective in specific areas of public health. Among them are the World
Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as
bilateral development agencies, public-private partnerships and

All of this has contributed to “a lack of agreement and lack of clarity of
what we absolutely need WHO to do versus what other organizations can do,”
said Dr. Suerie Moon, the director of research at the Global Health Center,
Graduate Institute of International and Development Studies, Geneva.

A new director-general will help determine what direction the agency should
take. But whatever his or her vision, it will face a daunting succession of
hurdles to change. WHO operates a heavily decentralized regional and
country system and unruly bureaucracy; faces powerful industry,
institutional, and advocacy group lobbying; and has a relatively small,
heavily earmarked budget to finance its work around the globe.

A new director-general will need to decide whether to prioritize the
demands of its member states or to focus on the broader public health good.
While current leader Margaret Chan has tended to defer to member states,
one of her predecessors, Gro Harlem Brundtland, earned a reputation as not
being shy about lobbying presidents and foreign ministers.

“The new director-general needs to be a leader who brings countries along
with a clear vision for global health, and who adheres to this vision
despite competing priorities of a few member countries, industries and
advocacy groups", said David Heymann, a former assistant director-general
for health security and environment at WHO, now head of the Centre on
Global Health Security at Chatham House.

New election, new rules

The May WHO election will take place under new rules, amended during the
meeting of the World Health Assembly last year, following concerns about
the last election in which Margaret Chan ran unopposed. Under the reformed
process, the director-general will no longer be chosen by the 34-country
executive board. Instead, the board will narrow the pool of six candidates
down to five on Jan. 24. The next day, the executive board will interview
the remaining candidates and select three finalists. The full 194 country
members of the World Health Assembly will choose the new WHO leader from
among these three candidates by secret ballot in May.

There are few confident predictions as to who might win. Many of those
interviewed by Devex believed that the final three candidates will include
Douste-Blazy, Nabarro, and Tedros, with Nishtar as the likely fourth.
Bustreo is thought to be testing the waters for a run next time around.
Szócska is seen as an outlier, though that doesn't rule him out.

Despite the more open contest, insider U.N. politics may still carry the
day. The reforms grant one vote per nation, but some senior officials tell
Devex the real decision-making could be done with horse-trading over the
dinner table, as countries and regions bargain over who gets to run which
international agency.

The fact that four of the six candidates are from Europe could play in the
two non-Europeans’ favor. The same is true for gender, which is less of an
issue in the context of the WHO by itself but rather in the context of
female leadership across the U.N. system. The early culling process could
also involve “strategic voting,” meaning that in choosing the final three
candidates, board members might vote for a weak candidate so that their
preferred candidate will have a better chance to win.

“All too often the overriding reasons for a vote have to do with diplomatic
quid pro quos, offers of development aid, or geopolitical concerns that are
peripheral or even antithetic to the functions of WHO,” former Mexican
Health Minister Julio Frenk, a candidate for director-general in 2006,
wrote in an email to Devex.

“Secret voting makes accountability impossible and opens the door for
outright corruption; even if the latter happens only in a minority of
cases, the legitimacy of the entire process is undermined.”

A Guinean doctor, who is part of the WHO contact tracers team visiting a
community in Conakry, Guinea, checks a patient’s temperature. Photo by:
Martine Perret / UNMEER / CC BY-ND

Part two

While everyone seems to agree on WHO’s lackluster performance during the
Ebola crisis, experts, officials and member states have drawn different
lessons from the crisis.

Wealthy countries such as the United States want the incoming
director-general to prioritize emergency response capabilities to combat
outbreaks they fear could affect them. Others worry that focusing on
pandemics could divert attention from more fundamental issues such as
building stronger in-country systems. After all, Ebola’s devastation in
three of West Africa’s least developed countries demonstrated that without
an effective basic health system, no country will be able to weather a
health crisis well.

The danger in focusing on pandemic response at the expense of general
health strengthening is that of fighting the last war, said a senior health
official from a major donor country. “When pandemic threats come everybody
gets into a panic,” said the official, who spoke on the condition of
anonymity because he was still involved in sensitive issues.

This past May, the World Health Assembly agreed that WHO needed to
establish a special program to provide operational capabilities to respond
to outbreaks and humanitarian emergencies. Former USAID global health czar
Dr. Ariel Pablos-Mendez described the new program in an essay as seeking to
“bring speed and predictability to the WHO’s emergency work by establishing
one clear line of authority, one workforce, one budget, one set of rules
and processes, and one set of standard performance metrics.”

Yet WHO was slow to respond to Ebola in part because its specialized
pandemic response unit had been abolished in the months before the outbreak
as part of budget cutting and reorganization. “One of the outcomes of that
was the decision to decimate the global outbreak preparedness and response
capabilities of WHO, and that came back to haunt them,” said Gostin.

The tension between crisis response and more core functions is one of the
primary struggles candidates have discussed in the lead up to the election.

In interviews with Devex, all candidates spoke about balancing emergency
response efforts with broader functions of the agency — no small challenge,
as several acknowledged. The WHO needs to be “agile” in responding to
outbreaks, including by knowing what not to do, Szócska told Devex. He,
Nishtar, Nabarro and Bustreo, all suggested to Devex that WHO needs
stronger partnerships across the health sector.

“In the domain of emergencies, there are so many potential partnerships,”
Nishtar told Devex. “I think it’s a question of a mindset. That you know a
leader has to think, OK, this is what needs to be done to achieve my
objectives … and how can we partner with [various actors] to achieve the
objectives we want to achieve?”

Some senior WHO officials told Devex they doubt whether WHO should be
taking an operational role at all; they argued the agency is better suited
to convening the various global health actors and providing leadership and

In fact, there is already an emergency response system in place, the
International Health Regulations, which were passed by the World Health
Assembly in 2005 in order to create a global system of pandemic
preparedness. WHO oversees the IHR but has little enforcement authority
beyond a bully pulpit. Currently, around two-thirds of countries are not
meeting the surveillance and response requirements, and donor countries are
not providing enough funding and expertise to help poor countries develop
their own pandemic prevention capabilities.

If IHR had worked, experts such as Heymann and Gostin argue, Ebola might
have played out quite differently. Instead, once the Ebola crisis was
declared, many countries flaunted WHO’s advice. The United States, for
instance, implemented travel restrictions and quarantines on returning
health workers. If countries fear they will face economic sanctions or
stigma from declaring an outbreak, it undermines the whole global health
system, said Liu.

Treating health while fighting disease

Advocates for health system strengthening point to the Zika virus as a
contrast to Ebola — an example of how WHO’s capabilities can be leveraged
to great effect. The agency’s response to the Zika crisis was “hugely
positive” said Guilherme Patriota, the deputy permanent representative of
Brazil to the United Nations.

Soon after Brazil sounded the alarm, WHO moved quickly to declare an
international health emergency and effectively coordinated between its
headquarters in Geneva and its regional offices, as well as national and
local levels of government in Brazil and other affected countries, said
Patriota. The agency also managed to build an aggressive response without
creating hysteria and unduly disrupting the 2016 Rio de Janeiro Games, he

“We don’t want a shift that will be too top heavy in the direction of
emergencies,” said Patriota. “As Zika taught us, you don’t know what the
next emergency will be.”

WHO’s value for a country such as Brazil goes well beyond any one outbreak,
argued Patriota, calling the agency “one of the U.N. institutions more
credible and present in our daily lives.” Brazilian public health agencies
take WHO’s guidelines and agenda very seriously, he said, both on things
such as infectious disease and emerging issues such as unhealthy food. “It
is a beacon for public health globally.”

Indeed, WHO’s presence on the ground in so many countries gives it the
ability to influence the public health agenda around the globe. WHO needs
to be pushed back to “the heart of the global health policy,” Douste-Blazy
told Devex.

While today’s global health ecosystem is populated by a growing number of
disease-specific organizations, WHO is the network hub. It’s where critical
discussions are held and guidelines are set on issues such as essential
medicines and diagnostic tools, infant nutrition, strengthening the health
workforce, and addressing the external factors in noncommunicable disease
such as smoking, food, and environmental pollutants. Traditionally,
developing countries have relied on WHO’s norms and standards to craft
their regulations, though this has declined as more countries develop their
own public health expertise.

One area rich and poor countries alike may increasingly look to WHO is
noncommunicable diseases like cancer, diabetes, and cardiovascular disease,
which have overtaken infectious diseases as the leading causes of death
around the world.

Some health analysts told Devex WHO can make its greatest contribution by
focusing on factors that influence these chronic conditions such as
infrastructure, economics, food quality and environmental pollution, rather
than focusing on a particular disease. One WHO success that may be
replicable in other areas was the tobacco-control treaty, which called for
limiting advertising, smoking in public places, and sales to minors, while
encouraging higher cigarette taxes. The treaty was ratified by 180
countries despite a forceful lobbying effort from industry.

“It needs to be the world health organization, not the world medical
organization” one WHO official told Devex.

That holistic approach could apply to WHO’s role in health care funding as
well. All countries face the challenge of how to create effective and
affordable health systems, said Ok Pannenborg, a former chief health
adviser at the World Bank who recently served as an interim director of
PAHO. He argued WHO should expand its focus to macroeconomic aspects of
health, such as helping countries develop their health insurance systems,
fostering a sustainable health workforce, and engaging with national
employment institutions, since health workers now make up one of the
largest sectors of the labor market in most members of the Organization for
Economic Cooperation and Development and many middle-income countries.

“It would benefit and strengthen WHO’s leadership and position in global
health if they devoted increased attention to these new macroeconomic
challenges,” said Pannenborg. He thinks that some of WHO’s initiatives such
as universal health coverage and its work on treaties such as tobacco
control help keep the agency relevant for a broad spectrum of member states.

Delegates of WHO’s member states at the 69th World Health Assembly. Photo
by: L. Cipriani / WHO

Part three

Perhaps the most difficult — and many insiders and candidates say the most
important — issue for the incoming director-general will be to deal with
WHO’s relatively small and inflexible budget. Over the last two decades,
WHO has come to depend heavily on earmarked donations. Currently, WHO
receives only 20 percent of its roughly $4 billion biennial budget in dues
from member states. The remaining 80 percent is made up of voluntary
contributions, most of which are allocated for specific programs.

That leaves the director-general with little room to maneuver and “puts the
integrity of the organization at risk,” said a senior WHO official who has
worked on budgetary matters and spoke on the condition of anonymity because
they are currently serving in a sensitive capacity. When it comes to
determining WHO's agenda, the loudest voice in the room is often that of
funders, not global health experts.

Moreover, donors are notoriously faddish when it comes to global health
priorities. They often favor funding for "quick wins" and "low-hanging
fruit.” Twenty percent of WHO's total budget goes toward polio eradication,
for instance. When the disease is eventually conquered, as expected, the
organization will suddenly lose a big chunk of funding.

Yet even without the earmarking, WHO's budget — which is less than
one-third of the budget of the U.S. Centers for Disease Control and
Prevention  — would be far too small for its ever-growing global mandate,
experts say. “There has to be a way to contain the demands for the work of
the organization,” Bustreo told Devex.

Director-general candidates have spoken at length, both with Devex and
elsewhere, about their ideas and goals for giving WHO more financial leeway.

Bustreo told Devex that she would seek to boost donations from new sources
“dramatically, exponentially,” while Nishtar emphasized the importance of
partnering with other actors in public health who can take on
responsibilities. Douste-Blazy highlighted his past work in innovative
financing mechanisms, such as a small airplane ticket tax that funds
UNITAID. Szócscka also urged innovative methods such as placing a global
tax on products that contain “too much sugar, too much transfat, or too
much salt.”

Nabarro, who led the U.N.'s Ebola effort, told Devex that U.N. agencies
such as WHO are important “as much for what it prevents happening, as for
what it actually does.” He said he intends to leverage economic and
political arguments about prevention to get both assessed and voluntary
contributions up. Tedros also emphasized conversations with members states.
He will make the argument that, since they only contribute to 20 percent of
the budget, they are not really the decision-makers at WHO. If they want
influence, he told Devex, they need to substantially increase their buy-in.

One possible source for budget expansion comes from developing countries,
many of which have grown enough that they should be able to contribute
more, noted an official with a major donor country.

Baeza, who formerly led the global health groups at both the World Bank and
McKinsey and Co., suggested taxing donor funded programs, so that say 20
percent of earmarked funds would have to be available for WHO core funding.
Otherwise, he says, “WHO is basically just a contractor.”

And yet part of the budget question is likely to involve tough choices
about what WHO just simply shouldn’t do. Niche or disease-specific
organizations may be better suited at some of the tasks that the agency
does now.

“It’s choosing what to do very carefully,” Nabarro told Devex. “[B]eing
selective is the best way to influence and being a strategic leader for me
is really the critical role.

Big challenges for a new leader

Whomever takes the helm at WHO will really be taking on two roles: forceful
manager and deft politician. Many are looking for a substantial break from
the past.

Current director-general Chan’s preference throughout her decade in office
has been to lead from behind, regularly making the point that she follows
the wishes of the member states. “She has been deferential to her member
states, and that’s been well received,” said a senior American official who
works on health issues but spoke anonymously because they were not
authorized to speak publicly.

Yet some yearn for a leader who goes beyond the typical U.N. consensus and
can be out front on issues, naming and shaming, and pressuring member
states when need be. These critics argue that the real client is the
collective health of the world's nations, not just the political needs of
donor states.

“It is in the best interest of the patient to tell them things that they
don’t want to hear and maybe to do things they don’t like,” said Baeza.

A new leader may have to get tough with the WHO’s own bureaucracy if they
want to reform. The agency has a three-tiered setup, with a headquarters
office in Geneva, six  regional offices with varying degrees of
independence, and 147 country offices. The vested interests of each pocket
of that structure could stifle attempts at reform.

“WHO’s bureaucratic structure is stultifying,” Suwit Wibulpolprasert of the
International Health Policy Programme in Bangkok, Thailand, and Mushtaque
Chowdhury, vice chair of  BRAC and a professor at the Columbia University
Mailman School of Public Health, wrote in the AJPH .

“Bureaucrats in WHO enjoy such lucrative benefit packages that they rarely
speak out or take risks. Some of the more committed and capable staff
simply leave the organization.”

Hiring, particularly in WHO’s country teams, should be merit-based, and
less a question of patronage, some candidates argue. “When you are
recruiting, you have to be very transparent on the process: Who made the
reference? What languages was it advertised in? What time period is given?”
Nishtar told Devex.

Shaking up the current situation will require that the new director-general
be willing to make waves — but that may prove difficult for a slate
composed of almost all insiders.

“If WHO does not adapt to the new reality, then they become increasingly
irrelevant,” said a former senior WHO official who spoke on condition of
anonymity because he still works with the agency. “If you get a traditional
director-general for WHO, then in the next 10 years the organization will
fade,” he said.

Devex Senior Correspondent Jenny Lei Ravelo contributed to the reporting
and writing of this story.

Stay tuned to Devex for more coverage and analysis on the election of the
next WHO director-general in May 2017.

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