David Nabarro is coming off several high-profile roles as U.N. special envoy heading into his candidacy for the World Health Organization. Ban Ki-moon’s representative for the Ebola crisis, and subsequently for the Sustainable Development Goals, Nabarro is a high-profile candidate with vast experience across the U.N. system.
But Nabarro’s career didn’t begin in international diplomacy, and the work he does today is informed by decades of experience working in the field for organizations such as Save the Children, in hospitals and within the U.K. aid agency, he told Devex.
“Everything I do now I think back to the people with whom I was working in villages and towns in Southeast Asia or in the Middle East, in Africa and a little bit in Latin America, [and ask] is what I do now actually going to impact on them or is it just going to pass over the top?” he said.
In this Q&A, Nabarro discusses the linkages between his work on the SDGs and the path he is pursuing now as director-general of WHO, the critical work of the U.N. agency, and the values he aims to instill within the organization to boost trust and confidence in the institution, particularly among donors investing in the organization.
You’ve had a decadeslong career working in health, including recent high-profile posts as U.N. Secretary-General Ban Ki-moon’s envoy on Ebola, Haiti and the Sustainable Development Goals. How do you view this candidacy as DG to the WHO?
I’ve been working as a health professional really all my life. And although I have been doing a lot of different roles, everything comes together and influences people’s health, whether you’re working on food or on broader development or on climate. So for me, to be given the chance to lead the World Health Organization is the right place to come to at this stage in my career. And obviously, I bring a particular approach. I think it’s the right approach for now, because the SDGs, which are a remarkable global agreement, are the plan for the future of the people and the planet.
If the SDGs are implemented, health will improve. But at the same time, for the SDGs to work, health has to be good. Women cannot be empowered to play their role in development if they do not have access to health care, particularly around maternal and reproductive health. Adolescents cannot contribute if they have not had good nutrition early in life. I see the link between health and the sustainable development agenda as a very close and exciting one.
I also believe that there are some big threats associated with disease, and we’ve seen that with bird flu, we’ve seen it in some of the other pandemics that have been upon us, particularly HIV and also the H1N1 flu strain. And then we’re seeing more outbreaks, perhaps fuelled by changes in the way we live or changes in climate. Having a strong system to enable communities, nations, and the world as a whole to be protected against this threat is really important, and that’s part of WHO’s responsibility.
Whoever wins among six candidates for the director-generalship of the World Health Organization will have a consequential impact on the future of agency and of global public health itself. Candidates are promising leadership and bold change. But any reform will have to contest with a WHO's fraught budget, demanding member states and a stultifying bureaucracy. Devex takes an exclusive look at the stakes behind the vote.
Lastly, there’s the whole area of health care. If we look at how the world is evolving, people are living longer. We’re living fuller lives. At the same time, [we’ve] got better access to health care, but not everybody has access to the care they need. There are big differences often relating to where you’re born or which community you belong to. I think there’s a very exciting and important area of work [to be done] on ensuring everybody has access to the health services they need, particularly those who are less able or those who are getting older.
Taken together, these challenges are challenges I relish and would enjoy. They are also challenges where WHO has a really significant role, and I would like very much to be given the chance to take that work forward.
You mentioned access to health care, which links into the current push for universal health coverage today. The SDGs also call for quite a bit more to be done and targets to be reached. How do you plan to move the organization forward?
There are a few things in that question. The first is to recognize that WHO as an organization is really very small: 8,000 staff with a budget of $4 billion in two years. It’s not a sizable organization, given the work that is expected of it.
So for me, the issue is WHO looking all the time for the most effective ways to use its position and influence to ripple out and affect hundreds, perhaps thousands of other different organizations that are working on the same issues. It’s being a lead organization, and the world is more and more experiencing the development of quite complicated interactions between different organizations working on challenging issues.
This is ... within the spirit of the SDGs. But you always need within that a central focal body, which sets standards, which you can go to when there are uncertainties about the right way to go, and which you can also ask to help with measuring and assessing progress. Those are the functions that the WHO can do best, and should do. There is a special role also for WHO within that context: [the organization] can sometimes catalyze different groups to work on particular issues, like recently on childhood obesity.
That’s an important role, but it’s absolutely not doing everything. It’s choosing what to do very carefully. Sometimes we use that term “very strategic” — being selective is the best way to influence and being a strategic leader for me is really the critical role.
You made another point, which was about the SDGs being complicated. Now, life’s complicated. I [would] much rather the SDGs reflect reality rather than we try to pretend that reality is somehow simple and can be solved easily. That capacity to actually recognize in a U.N. process the SDGs — that things are complex and interconnected — is a good thing. I turn it around the other way, and I say, all of us who work internationally have to learn to live with the complexity and not to say “oh dear, it’s too complicated we got to simplify it.” That’s one of the big challenges in my current job. My work on the SDGs is to help governments, U.N. organizations, businesses, civil society and others to connect with each other, so that they manage the complexity without getting kind of very disturbed. It’s happening right now. It’s very exciting to work.
Over the past year, the WHO has had quite a number of issues and questions to wrestle with — from funding to emergencies to the organization’s very relevance. How do you plan to address them?
Let me start with relevance. I’ve already mentioned in this complex and interconnected world of sustainable development, it’s really important to have organizations that can help establish standards, to deal with technical questions, and also to catalyze others so that they can work effectively on issues. That’s hugely relevant and there’s actually no other global body that has the legitimacy to perform in those functions.
I would actually counter by saying organizations like the United Nations as a whole and it’s different specialized agencies are enormously relevant in today’s world and need to be not just protected and preserved but helped to engage in some of the issues I’ve described.
So relevance — no question. And in fact, the big challenge will always be to ensure that our organization, the WHO, makes the best possible choices about how its resources are used.
There are always people who question the relevance of multilateral organizations like the U.N., but they’re people who perhaps discount the significance of standard setting, of resolving complex technical issues and of catalyzing actions by others.
Without having a standard setting body, it’s very difficult to have clarity on what is good and what is less good for your health. Without having a body that could help resolve disputes about different policies, again it’s very difficult for governments and others to be able to say to their people we’re following the internationally recommended approach. This for me is just so relevant. The only people who might possibly question the relevance [are] people who are actually trying to fight against standards being set and have their own motives. But I have not honestly heard serious questioning of relevance, and when I do hear it, I find people perhaps haven’t thought the issue through.
Let’s try to come to the next issue, which is outbreaks and emergencies. Disease outbreak is one of the most challenging issues in global diplomacy, because when an outbreak is starting, you don’t get a little flag that comes up from some computer somewhere saying “outbreak starting here.” And then it sort of gets picked up on a satellite and we can all go off and deal with it. It’s never quite like that.
What actually happens is that [you] get perhaps a cluster of strange events happening, people being sick or even animals being sick, and then people looking after animals getting ill. At times it’s quite tricky to actually understand and pick it up, especially when the sickness might be children being born with small heads [as with the Zika virus].
So the first thing is to have a population of public health-trained people who are alert, capable of sounding the alarm and then capable of responding in an efficient way that puts people at the center of the response.
But then there’s a problem: There may be others in the community who get very nervous of the alarm being sounded. That means you’re going to get people descending on the community in light vehicles and perhaps coming with military and others, because there is always fear when there is infectious disease that might spread. Then you get another community who would say, wait on [it] a bit. Are we really sure? Do we really want this to happen? Especially if they have other interests, economic, tourism or whatever.
So it’s never straightforward, this business if identifying outbreaks and responding to them.
And then if you’re not quick when the outbreak is starting … you can end up with a very big problem.
The issue of becoming more effective in responding to outbreaks and emergencies is also an issue about trust, within countries, of the public health people, and trust between countries that things are being done fairly and properly. It’s also a case of making sure that people, businesses, civil society groups are informed and they don’t take actions particularly with regard to keeping away from other people or banning other people. They don’t take actions that are unwarranted.
So there are a lot of very important issues to deal with the style and the influence on personal behavior. If you do it through fear, then that can create some very difficult problems.
The issue of being good at outbreaks and emergencies is not a simple thing. It’s not like trying to run a machine and make sure the machine is efficient. It involves a lot of relationships, and that’s where WHO, again because it’s the standard bearer for health, has an absolutely critical role and that’s why the work on trying to transform the organization so that it’s more trusted in dealing with these outbreaks is a continuous process. I’m very pleased that that’s been taken seriously by this director general and that’s something I’m really keen to take forward, because I have some experience in doing that work.
Lastly on financing: Yes, WHO has a very tight budget. At the same time as every international organization. There’s often a community who say, “well the trouble with the United Nations is that it spends a lot of money, but we don’t get a good result from it.” We know that those people exist and it’s a bit frequent you hear those conversations because really investing in the United Nations is like buying insurance. You’re investing in trying to keep yourself safe and secure. And we all know that there’s [been] a time in your life when you bought an insurance, especially if it’s not compulsory, when you think, do I really need this? And when you don’t buy the insurance and then suddenly something terrible happens, then you really regret it.
That’s the way I try to describe it to people. We need the United Nations as much for what it prevents [from] happening as for what it actually does. The preventive work you just don’t see. My commitment when I’m director-general — I’m going to say when because I don’t know whether it’s true — is to continue the dialogue with the different groups of people who provide funding and just work with them to establish the true worth of the WHO: To appreciate what it stops, and what it prevents, and what it encourages, and what it contributes, and put that in economic terms, political and social terms. And to do it fairly.
I think we will see over time, because I’ve seen it in other areas, that we can shift to baseline and get first of all the voluntary contributions up, and then get the assessed contributions up.
I’m not scared of that. It’s about confidence and trust between the investors and the organization, and it’s about doing it carefully and honestly. Never exaggerating, otherwise people won’t believe you, and also at the same time, appreciating that those who finance the U.N. and WHO in particular need to be able to explain to their people what they are putting money into. We have to work with them on the financing case. I left that to last, because it’s the most important challenge of all that you identified.
Do you see anything that needs immediate and drastic change at WHO?
One of my responsibilities last year going to early this year was to chair an advisory group on transforming WHO’s work in outbreaks and emergencies. And yes, we found things that needed to change, and we put them in the recommendations. I presented those recommendations to the executive board last January, and not everyone ... is comfortable, because it does require change in the culture of the organization as well as changes in a lot of the operating procedures. But they are being implemented.
It’s actually keeping that work going that really inspired me to want to come and be the leader. I’ve had a very close and constructive working relationship with Dr. Chan, who has been introducing these changes, and I know where they’ve got to get to, which is to continue and not to in any way hold back in the changes already happening. The last thing you want to do is have a process of change under way and have somebody else come and say, oh that’s no good, we’ll completely throw it out. Especially when what’s being done is right. I’d want to continue with even more energy, even more commitment on these outbreaks and emergencies work, to get in five years time to where WHO needs to be in terms of the capability and the confidence that it has in dealing with these issues.
Capability means they do it well. Confidence means that other people see that they are doing it well.
WHO is also a largely misunderstood organization. Some think it should be doing operational work, like MSF. Some think it’s a funding agency. Do you have any strategies for how you plan to communicate what exactly the organization does?
The term I use is strategic leadership, which means helping everybody to know where they should be aiming for and have an understanding of some of the pathways that would help them get there, and then to help them to do it on the way. It’s illuminating the path, identifying the destination, and helping to check you’re getting there.
It’s not actually doing all the work. WHO is too small to do that. So it’s quite a sophisticated role, and there have been people who questioned and criticized [the organization], and perhaps one of the most important things that we’ve learned is you can’t do that direction-setting, pathfinding, supporting role if you don’t have very good people close to where the problem is. You can’t do it from some office far away.
One of the consequences of that is we have said there needs to be the capacity of WHO to get close to operations and to understand what’s going on. But that doesn’t mean doing it. In fact, it means being ready all the time to help others to do it.
Does that mean adding more staff on the ground, if the budget would allow it?
It means some WHO people, but it also means when you’re surging for a particular problem, being able to borrow good people from the member states, who are after all part of WHO, and being able to deploy them as well. The key thing is the capabilities of those people have to be the capabilities of strategic leaders.
You’ve worked with WHO and the wider U.N. system for many years. Do you find it an advantage or disadvantage?
Well first of all, it might look like I’ve worked for the U.N. forever but I haven’t. I started working in NGOs in 1974 and also working in hospitals. I served between the two for around 10 years, and a bit more actually. And then I worked as a teacher in tropical medicine, for being a teacher you also learn. And then I went to government for 10 years and worked in running really complex operations for the British Foreign Office and then the British development office.
I went in WHO very much doing technical work on malaria [and] emergencies. It’s only recently that I’ve become what you might call an international public servant — that’s really about since 2005. I went to join Kofi Annan [when he was] U.N. secretary-general in New York. So it’s really quite a progression, my life, and it’s useful having [those experiences.] It means everything I do now, I think back to the people with whom I was working in villages and towns in Southeast Asia or in the Middle East, in Africa and a little bit in Latin America, [and ask] is what I do now actually going to impact on them or is it just going to pass over the top? Having that kind of internal check and balance I think is really important and am privileged to have that.
Jenny Lei Ravelo is a Devex senior reporter based in Manila. Since 2011, she has covered a wide range of development and humanitarian aid issues, from leadership and policy changes at DfID to the logistical and security impediments faced by international and local aid responders in disaster-prone and conflict-affected countries in Africa and Asia. Her interests include global health and the analysis of aid challenges and trends in sub-Saharan Africa.
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