Next week the World Health Assembly, the decision-making body of WHO, will appoint the new WHO Director-General. This poses a few interesting questions including: what will the incoming DG need to focus on; how were the candidates chosen; how might the voting system influence the decision; and, finally, why should you care who gets the job?
To take the last question first, the role affects us all because WHO sets the global health agenda, an agenda that trickles down and is reflected in regional and national level policy (think breastfeeding policy, access to medicines, clinical guidelines, investment in new drug research, and so on). The DG oversees the technical and administrative side of the Organization , is the public face of the agency and heavily influences the agenda and priorities pursued by the WHO.
Dr Margaret Chan was elected to the post in 2006 and, as tenure is limited to two five-year terms, she must pass the baton on 30 June for the new incumbent to take office on 1 July. A communicable diseases expert, Chan used her time as DG to champion pandemic preparedness, including the detection, active surveillance, monitoring and sharing of data relating to epidemic-prone infectious diseases. Her skillset was duly tested, with calls to action to address outbreaks of SARS, MERS, avian influenza, and of course, Ebola and Zika (a non-exhaustive list, addressed with varying degrees of success).
With Chan’s directorship drawing to a close, what will the incoming DG need to focus on? First on the agenda will be continuing reform to improve the efficiency and perceptions of WHO. This is important because the agency needs to convince key benefactors that it remains deserving of funds as the best-placed organisation to lead global health efforts. Pressure for change has been building after a series of failures with WHO at the helm (including the mishandling of Ebola). It is now imperative for WHO’s survival that the incoming DG improves its reputation and raises core funding from national governments, particularly the US, which under the Obama administration contributed $US834.7 million biennially to the Agency – a significant portion of its overall budget. Failure to address the Agency’s image could result in further reallocation of WHO’s remit and budget to other UN agencies (including UNAIDS, UNICEF), government initiatives (such as PEPFAR - President’s Emergency Plans for AIDS Relief), and/or Public Private Partnerships (Gavi, the global vaccine alliance, is one example). Government initiatives and PPPs would appear to be the more likely potential beneficiaries given President Trump’s public criticism of the UN. In December he tweeted the UN ‘has such great potential but right now it is just a club for people to get together, talk and have a good time’.
The new DG will also need to navigate key political challenges, such as the refugee crisis, health security issues, including climate change and antimicrobial resistance, and the 2030 Agenda for Sustainable Development, all whilst responding to existing and emerging health threats.
This year, candidate shortlisting and final selection follows a new process deemed to be more efficient, transparent and consultative. Between April-September 2016, all 194 WHO member states had the opportunity to nominate candidates: six emerged. Candidates then ran the gauntlet during two WHO-run forums in October and November, the latter requiring a 30-minute presentation on their candidacy, with a further 30 minutes dedicated to answering pre-submitted questions which were drawn by lot. In January, WHO’s Executive Board shortlisted three of those six candidates (previously, only one candidate was submitted by the Board for consideration by the World Health Assembly). Those three candidates are: Tedros Adhanom Ghebreyesus, nominated by the government of Ethiopia; David Nabarro, nominated by the UK; and Sania Nishtar, nominated by Pakistan.
Tedros Adhanom Ghebreyesus (who goes by his first name only) is Ethiopia’s current minister of foreign affairs and previous minister of health. He has a PhD in Community Health and an MSc. Immunology of Infectious Diseases, and has held board positions with the Global Fund, UNAIDS, GAVI, and the Roll Back Malaria and Stop TB Partnerships. David Nabarro is currently special adviser to the UN Secretary-General on the 2030 Agenda for Sustainable Development and Climate Change. He is a medical doctor with a MSc. Public Health (Developing Countries), and has led and advised UN efforts on avian and pandemic influenza, food security, malnutrition and Ebola. Sania Nishtar co-chairs the WHO Commission on Ending Childhood Obesity and was formerly a minister in the Pakistan government. She is a medical doctor (and Pakistan’s first female cardiologist) who has led and advised extensively at WHO, UN Agencies and international NGOs including the World Economic Forum and Gavi.
All three candidates have impressive experience and credentials, but at this level being an overachiever is a prerequisite. All three campaigns have also been relatively similar, although Tedros has focused more heavily on access challenges while Nabarro and Nishtar concentrated on governance and accountability, reform and coordination. With this in mind, the ultimate decision will likely be informed by other factors. For example, neither the Eastern Mediterranean or African Regions have been represented at DG level. The growing calls that it is ‘Africa’s turn to lead’, may work against Nabarro.
However, Tedros is not a medical doctor, which would be a first for a WHO DG. And, despite being officially endorsed by the African Union, his candidacy is not without controversy. This includes accusations of cholera cover-ups whilst minster for health, and ‘misspending’ HIV-aid from the Global Fund, which resulted in $US6 million being returned to the Fund (Tedros denies the misspending and says funds were returned only because they were used after the deadline had passed).
Then there is the voting system to consider. Next week, member states will vote in a secret, one-country one-vote process. WHO’s African Region represents 47 countries (though the African Union is a block of 54 countries) and this might push more votes towards an African leader than an Eastern Mediterranean leader, which is a 21-country block. Further, the effects of Brexit on Nabarro being WHO EURO’s sole remaining candidate are not known. That aside, the EURO region is extremely heterogeneous (encompassing Portugal to the West, Russia to the East, Turkmenistan to the South and Norway to the north – and, having had multiple ‘turns’ at DG, countries in the region are possibly less-inclined to ‘vote for their own’.
Though Nishtar hails from the smallest block of countries, she has the support of the Organization of Islamic Cooperation which has 57 Member States and serves as the collective voice for Muslims. In addition, some member states (these could be those that are African and Muslim, or African but anti-Tedros, or European but pro a DG from a developing country) may direct their votes towards her because they want to see the first-ever Muslim woman and the first-ever woman from a developing country assume the role. Further, unlike Tedros whose candidacy elicited strong opposition (albeit from a small faction), and Nabarro, who – apart from being male and British – represents a very strong contender, Nishtar would represent a DG with wide appeal, and might just emerge victorious. If so, she could be the strong, refreshing and inspirational leader that WHO needs to raise funds, lead with technical competence, build consensus and, ultimately, write the next chapter in global health diplomacy.