Tedros' 100 days in office

World Health Organization Director-General Tedros Adhanom Ghebreyesus. Photo by: WHO

MANILA — When World Health Organization Director-General Tedros Adhanom Ghebreyesus announced his leadership team last week, it was hard to imagine him garnering anything less than a positive thumbs up for his first 100 days in office.

The team has all the makings for a positive review: it represents all WHO regions and more than 60 percent are women. The selection, many argue, show how it’s possible to achieve diversity without sacrificing talent.

At a time of increasingly greater demand for gender equality at the leadership levels of U.N. agencies and development organizations, Tedros’ move struck a strong chord among many advocates who, until the announcement was made, were cautiously optimistic of the WHO director-general delivering on his promise of gender equal leadership. It also seemed to symbolize a largely positive reception for Tedros’ first three months on the job that have seen him trot the globe advocating effectively for WHO, reach out to staff internally and plot an ambitious road ahead — although questions remain on just how much he can deliver.

Unlike the much publicized election campaign for the WHO director-general position, the process of picking the senior leadership team was largely confidential. The only name that surfaced before the announcement was that of Dr. Soumya Swaminathan, who would become his deputy director-general for programs.

The picks followed backlash to an August brainstorming session between Tedros and World Bank President Jim Yong Kim, when a photo of the meeting posted on Twitter revealed zero women at the discussion table among more than a dozen men. Although Tedros was quick to address the issue on social media, it raised concerns over what the senior team at WHO would look like.

But all that talk vanished as soon as names of his leadership team were published. Almost everyone Devex spoke to right after the announcement had congratulatory remarks for the global health leader.

“It’s a great senior line up [and] a break from the past. We are delighted that Tedros heard the message of the [Women in Global Health] movement and shares our understanding of the importance of women’s leadership for delivering better global health,” said Ann Keeling, policy fellow for Women in Global Health, adding, “Tedros deserves a pat on the back on this one!”

Katja Iversen, CEO of Women Deliver, said Tedros has set the bar high for gender parity and diversity, one that she hopes will be taken up across all levels of WHO and inspire other organizations.

The announcement was followed by another similarly high-profile and well-received appointment: The WHO aid chief has recruited Dr. Sania Nishtar, whom he ran against for the director-general position, to chair a high-level commission on noncommunicable diseases that WHO will be establishing ahead of the third U.N. high-level meeting on NCDs in 2018.

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At the 68th regional meeting of the WHO Western Pacific office on Thursday, he also appointed Elizabeth Iro, secretary of health of the Cook Islands, as WHO’s first chief nursing officer. Iro will be part of Tedros’ senior leadership team.

The appointment of the senior leadership team is one that the global health community had been anticipating, but it’s not the only item on the aid community’s list. Tedros has made a number of promises during his campaign for the director-general position, and the aid community, along with his staff, have been watching closely, charting the progress or lack thereof on each item.

Tedros’ early ‘accomplishments,’ according to his advisors

Everybody agrees it’s too early to make judgment on what the WHO director-general has accomplished to date. Tedros took over the organization in July, about a month after his election at the World Health Assembly. But be it his 100 days in office, or first year, Tedros is doubtless fully aware eyes are on him and the changes he is expected to put in place in WHO’s work and functioning.

“I am proud of everything we have accomplished together in the past 3 months,” he told WHO staff and member state delegations on Thursday, when he highlighted the global momentum for universal health coverage and health security.

“But the clock is ticking. We have just 13 years to keep the promises we made to the world’s people,” he said.

His senior advisers believe Tedros can count three major accomplishments to date. First is the completion of his leadership team. The second is his high-level diplomacy work, which has allowed him to refresh the discussions around resource mobilization for WHO and global health at large.

“He feels extremely strongly that WHO is the only member state-owned agency, and that he shouldn’t really be putting out a bucket to beg money,” said Tedros’ senior advisor Dr. Senait Fisseha. “The financial resource mobilization needs to change from a financial monologue to a financial dialogue where member states have to take responsibility to raise the resources for the WHO.”

Third is the roll out of a new strategy contained in the draft concept note for WHO’s 13th general program of work. In it, he talks about major shifts in the way WHO should go about its business, from a focus on results to WHO adding a function of becoming operational in certain contexts.

The process traditionally takes up two years, and budget negotiations often start long before the framework is finalized, said Fisseha.

But Tedros is fast tracking the process to have the program of work ready for discussion by the executive board, presumably as early as during a special session in November. Feedback from regional committees and informal online consultations for the program of work is set to close Oct. 13, and WHO targets to publish the draft 13th General Program of Work on its website by Nov. 1. If all goes well, the board could consider the draft in January and submit it for final consideration and approval at the World Health Assembly in May 2018.

With this timeline, Tedros could have an early kickstart in mobilizing resources for WHO’s programs and potentially align the budget to approved priorities.

In the old process, “the budget request comes before the strategic framework, so he’s really changing and that’s a fundamental change. He’s truly bringing a whole new way of working at the WHO that’s efficient and that everybody’s been asking for,” Fisseha said.

The draft concept note for the 13th Program of Work includes:

Focus on results not just outcomes

Align its work with the Sustainable Development Goals

Implement clear programmatic priorities in line with the organization’s budget

Become more operational

Place emphasis in meeting countries’ needs

Provide political leadership across the global health spectrum

The changes contained in the draft concept note aren’t exactly surprising. Anyone who has closely paid attention and followed Tedros’ many speeches before WHO member states and in high-level political fora should by now be familiar with the direction he wants to bring his organization along. But some of the priorities raise critically important questions, such as what does it mean when the document says WHO will “become operational?”

“I think where I would want to really have more clarities or be clear on [is] where WHO’s role ends and begins,” said Loyce Pace, president and executive director of the Global Health Council, a membership organization providing support and connecting different stakeholders around global health issues.

“I think what he tries to do is outline where that would happen and why, particularly with countries most in need and especially in emergency situations,” Pace said. “But there’s a bandwidth question for me with regards to WHO’s operational capacity, and whether or not that subset of settings extends or contracts depending on certain contexts, certain crisis, on the level of resources of these countries [because] that can change over time.”

The aid community’s own checklist

Members of the global health community have their own checklists for the director-general. Among these is whether Tedros is able to listen, as he promised, to their recommendations; whether he’s being strategic in the use of his time and WHO’s finite capacities and resources; and how he is engaging the wider global health community in his leadership journey.

Those advocating for gender parity at senior leadership within WHO would be the first to acknowledge that Tedros is indeed listening, although they certainly hope Tedros would consider their other suggestions, as well. Women in Global Health, for example, has also asked Tedros and his team to appoint a senior gender champion that directly reports to him and for WHO to adopt a policy that ensures gender balance across its events, panels, or roundtable discussions, or that, “at the very least, set that as an organizational cultural standard to strive toward,” Women in Global Health Executive Director Roopa Dhatt told Devex.

Some members of civil society meanwhile felt encouraged with Tedros’ decision to engage with them, particularly on such an important topic as WHO’s future program of work.

In September, on the sidelines of the U.N. General Assembly, Tedros and his team arranged for a meeting with several members of civil society, to whom he introduced a concept note of his draft program of work for WHO for 2019-2023, and invited them to provide feedback — a process he has already carried out with almost all WHO regional committees. This week, he’s about to complete the process with the simultaneous regional meetings of WHO’s Western Pacific and Eastern Mediterranean offices in Australia and Pakistan, respectively.

“I think their goal was to really just kind of have an open dialogue with our community and let us know he was available to them, [but] I found that very encouraging — that him and his office were so open to engaging with sort of more people in the community, and not only with representatives of member states,” said Pace.

Pace said she thought the meetings were an indication that Tedros took to heart the recommendations made by members of the global health community, including civil society. In May, after the election, GHC drew up a list of recommendations for the new director-general. Top of the list was for Tedros to listen so he can better understand where the critical assumptions and opinions about WHO are coming from, helping him draft a clearer way forward.

“I think that he is rising to the occasion and what I see is a map for success and I’m encouraged by what I’m seeing so far,” Pace said. But “of course we still need to see how the strategy is implemented, how the leaders perform, and some of these other pieces in the coming months.”

Via SlideShare

Tedros and his promises

A particular hallmark of Tedros’ early days in office is his presence. He has appeared at almost every important political meeting and global health conference held in the past three months. Tedros attended the G-20 meeting in Hamburg, Germany, and the London Family Planning summit in July. He engaged in discussions with the Chinese government on their Belt and Road initiative in August. And he participated in key meetings and events during Global Goals Week in New York, from the U.N. General Assembly to the Global Citizen Festival, in September.

He spent this week in Islamabad and Brisbane to attend two of WHO’s regional committee meetings. Next week, he will be in Montevideo, Uruguay, to attend a major global NCD conference.

His senior advisor and close confidant, Fisseha, attributes this actions to Tedros’ background as a diplomat, but also in his conviction that health is not just a technical issue but also political.

“He’s a former foreign minister,” she noted. “He appreciates the importance of political leadership, and that health is not just a technical issue, that he needs to engage the heads of states at the highest level.”

She argued that in the short time Tedros has been in office, he was able to elevate both WHO and universal health coverage at the highest level by showing up at these political capitals and high-level meetings.

Tedros’ availability and presence in these different settings has gotten nods in the global health space. People appreciate that he is taking the time to be present at key political and global health events, as well as his efforts to understand issues from the ground, such as his trip to Yemen.  

The large amount of travel, however, has raised questions on how he is able to follow through on early promises to engage more with staff. And with him moving so much, has he had time to sit down and assess the issues within his own institution?

Devex reached out to the staff association in Geneva, but only a spokesperson replied, requesting that interviews go through official channels. Fisseha, however, believes Tedros has followed on his promises.

“He works round the clock. You see him, when he attends a meeting in D.C. or New York or G-20, he goes in, he goes for a day or two, and then he flies out straight from the airport to the [WHO] office [and then] doesn’t leave until 8 p.m.” she said. “He’s like a locomotive that just doesn’t slow down. [But] we want him to slow down so he can serve much longer.”

Tedros has implemented his open-door policy to staff every Thursday, and initiates meetings with staff, including the staff association and directors at WHO, the senior adviser said.

“He eats in the cafeteria with staff [and] walks with them through the hallways. He doesn’t use the special entrance designated for the director-general in the back. He understands WHO’s most valued assets [are] the staff,” she added.

But Tedros’ presence does not seem to penetrate across the organization just yet. The perception by some staff is that he travels a lot, and when he is in Geneva, he’s mostly engaged in meetings with high-level officials.

“In my view, some proactive ‘outreach’ on the part of the director-general’s office would be helpful as most people are, like myself, too apprehensive about going up to someone as high up as the DG … especially after the more top-down organizational culture of the past few years,” a WHO staffer who spoke on condition of anonymity told Devex.

This does not mean Tedros is not following through on his words. In fact, some staff confirm to Devex the WHO aid chief’s open door initiative, and one of them knew of three people who had appointments with him in the past three months. Their feedback: he’s been “highly receptive” and “friendly.”

“All staff have been welcome to provide him suggestions in a 15 minute face-to-face appointment,” one staffer, who also spoke on condition of anonymity, said. “That’s already more interaction with the staff than the previous DG had in her 10 years.”

This speaks to Tedros’ intentions of having more engagement with staff, which he has mentioned several times in speeches, but it also demonstrates that it requires a major cultural change that other high-level officials in the organization could well follow.

“He’s asking everyone to be the same, to lead by example. He’s now asked all the ADGs of course to be … [and] the existing teams and directors, and ADGs [to] please make yourselves available,” Fisseha said.

Tedros has also taken it as his task to resolve internal tensions and issues between teams, some of which have persisted for years and have affected the way the organization operates.

Fisseha didn’t elaborate further, although she gave the example of apparent longstanding issues between WHO and the International Agency for Research on Cancer when Tedros came on board, which the director-general discussed with the IARC’s director and teams.

“He said if we have issues, we’re going to sit down and solve it. We need regular engagement, and not only when issues arise,” Fisseha said. “As he repeatedly said, unless we’re healthy internally, we cannot be healthy and functional externally.”

This could have inspired a proposal in the WHO’s program of work concept note to incentivize cross-departmental collaboration, and disincentivize approaches done in siloes.

Tedros’ litmus test

Tedros has consistently called universal health coverage his top priority. He spoke of it earlier during his campaign for the director-general position, and has been putting it front and center in all of his engagements, whether in the context of drumming up support and investments from different political leaders, or in terms of how WHO should organize itself.

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He has noted that the road to UHC will be different in each country, and that to achieve it will require significant investments in country health systems — including better information systems and sufficient workforce equipped with the right training and skills — and finding the means to sustainably finance each part. Having a strong health system, he said, is vital to responding to health emergencies. He has also established a WHO Health Security Council that meets every two weeks to review all health emergencies communicated to WHO globally and how the organization is responding to each of them.

But WHO’s performance in health emergencies will not be the only litmus test on whether the institution succeeded in forging a path toward universal health coverage in countries. Advocates and policy experts will be gauging too how Tedros handles discussions on access to affordable medicines.

To date, some of them think Tedros has not highlighted the issue enough in his push toward universal health coverage.

“Dr. Tedros has talked about UHC, everywhere. At the UNGA he put universal health coverage and SDGs at the forefront. What I think is missing, to be honest with you, is the link between that and the link for affordable medicines. I don’t think [he has raised the issue] strongly enough,” an expert on the topic who spoke on condition of anonymity for fear of endangering their consulting work told Devex.

The source has found Tedros focusing much of his discussions on mobilizing resources for universal health coverage and “the right to health.”

“And that’s really powerful and really correct,” the expert said. “But I think I’ve not seen enough [discussion] for example about the existing policy incoherence between trade frameworks and the right to health and the SDGs.”

A discussion of the U.N. High Level Panel Report on Access to Medicines — which the source said specifically asks the question on how to solve the policy incoherence between trade, health, and the SDGs, a deeply complex, tension-filled discussion for sure — failed to progress at the last World Health Assembly, due to strong opposition from some rich powerful countries with large pharmaceutical industries. But advocates expected more from WHO, and were disappointed, having felt they didn’t get the necessary support from the institution that’s supposed to be “the moral authority on health.”

They are hoping Tedros will be more proactive in taking on the issue at the next executive board meeting, at the next World Health Assembly. And they hope he will fully implement some of the resolutions WHO has been mandated to do, such as the WHO Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, which the source said WHO has not fully implemented to date, despite it having been passed in 2008. An independent review of the strategy and action plan, released early this year, identifies several countries’ lack of awareness and engagement on the plan’s implementation.

But in implementing the strategy, WHO should consider the current contexts. Tedros should also apply the same political lens he has applied to health in general when discussing the issues of affordable medicines in political fora, the source said.

“Most of these mandates are about increasing access to medicines to the poorest countries of the world, and that’s extremely important. But if you look at where people don’t have access to medicines right now, they are everywhere [including] in middle- and high-income countries,” the source said. “There’s nobody safe from the issue of lack of access to medicines and vaccines.”

Similarly, Iversen, CEO of Women Deliver, was pleased when Tedros attended and spoke for women and girls during the London Family Planning Summit in July. But she hopes Tedros will be more “fierce” in advocating for girls and women’s health, rights, and well-being, including on matters of sexual and reproductive health, in his engagements with political leaders and across the work of WHO.

Tedros should also continue engaging youth and should create a youth advisory board that could be involved in co-creating policies and programs in development.

“If given seats at the table, we know that youth and civil society groups will push the WHO to be more ambitious, innovative, and effective at meeting the real needs of underserved populations,” she said. “Youth must not be forgotten from WHO’s priorities. Dr. Tedros will soon face the challenge of meeting the needs and aspirations of a rapidly growing youth population.”

While Tedros may have encouraging results in these early days of his tenure, the road ahead is long and the responsibilities longer. For him to sustain current optimism in his leadership, he will need to ensure he delivers on the ambitious roadmap he has initially set out for the organization — and more.

“History will be our judge,” he said in his Thursday regional committee speech. “Will our grandchildren admire our achievements? Or will they say we had a lot of meetings, and wrote a lot of reports, but didn’t achieve very much?”

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