Election sees WHO's future role in question

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 equipment.

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 Rights.

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 earmarks.

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.

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 philanthropies.

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.”

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 coordination.

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 said.

“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.

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.