As health minister of Ethiopia, Dr. Tedros Adhanom Ghebreyesus saw the impact of disease outbreaks and poor health care firsthand. He witnessed how malaria could devastate an agricultural workforce and leave crops unharvested. “It was really mind boggling, and for me it was unacceptable,” he recalled. During his tenure, he set out to overcome some of his country’s greatest health challenges and saw dramatic gains in indicators such as child and maternal health.
Now as a candidate for the World Health Organization’s director-generalship, Tedros seeks to take his efforts global. Ethiopia’s candidate has won the endorsement of the African Union’s executive council and is the only prospective leader from the continent.
In an interview with Devex, Tedros said his experience in Ethiopia has grounded his belief in building strong health systems as well as pushing for universal coverage. He promised to prioritize WHO’s role in global health, while also seeking input and consultation about how the organization can be reformed.
Tedros also points to his experience as a diplomat as a credential for his candidacy. The incoming DG will need to balance scientific priorities with the politics of members states and other donors. Tedros told Devex he will make the case for member states to increase their buy-in to WHO to a “controlling share” of at least 51 percent of the budget — up from 20 percent today.
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.
Our conversation, edited for length and clarity, is below.
Why do you want this job?
I have the passion to really do the job, and second, I have hands-on experience. I have reformed the health system of Ethiopia, and not only that, but I have seen the results of the reform myself. Because of my experience both in the health sector, and later on in the foreign ministry, I have developed the technical skills, the political knowledge and also diplomatic skills.
When I say passion, you know, I was born in Africa, I was brought up in Africa and I have seen firsthand how actually, the scourge of diseases it has affected communities, my own village and also communities, and even myself as a victim. I have seen also the impact malaria outbreaks or other health problems — not only on the health of communities but also economic impact. It's very clear by the way, you can see it without any knowledge of economics, when a good harvest is not harvested by anyone because everybody's bedridden.
That started to trigger in me: Why, why, why can't we really address this, why are people suffering? Is it because we don't have the means or is it because we don't want to do it? Why can't we do this? Why can't we save the lives of people? It just started to trigger many questions. Then I became a member of Ethiopia’s Ministry of Health, especially a member of the Malaria Control Program. .... I saw firsthand how devastating the malaria outbreak was.
We were doing the vector control, mass treatment and so on. We saved lives, we helped people, but still it was not enough, because the impact on the community was really huge. The whole community was bedridden and nobody's trying to collect the good harvest they had, and many of them also died as a result. It was really mind-boggling, and for me it was unacceptable. So that's why, from that moment on especially, I dedicated myself to health only. And that's why afterwards I did my master’s, my Ph.D. and everything, and all my research, because I was really sick of it and I didn't really accept that [this situation] should be the case. We have to do something.
As health minister, I had then the chance to really work hard to rollback malaria. That's why, in the last twelve years, in Ethiopia, there is no major epidemic of malaria, none, none whatsoever, and that really paid off.
What are the lessons from your own experience you would bring to WHO?
I'm a strong believer in a strong health system. You can't just fight malaria as a silo, it's through a strong health system that you can beat it. So side by side we started the reform to build the primary health care service delivery, the information system, the workforce, the health financing — everything. I was actually one of the longest serving ministers in Africa. We have achieved almost all of the Millennium Development Goals: Two-thirds reduction in under five mortality, maternal mortality was reduced by 71 percent. HIV mortality was reduced by 90 percent. Mortality due to tuberculosis was reduced by 64 percent.
This reform was based on WHO guidelines by the way. WHO advocates for reform of all building blocks of the health system, and that was what we had been following in Ethiopia. When I said I have the hands on experience and I can do a better job as the director-general of WHO, it's because I have implemented the guidelines, the reform of the building blocks of the health system, and as a DG, I can help countries to do that. I strongly believe in that, and I have done it, and I can make it at a global scale.
That I think is something that distinguishes me from others, the hands on experience, it's not just talking about the right things, but I have lived it. I have experienced it, I have been a victim myself, then I work as an expert, I confronted it. I confronted it as a minister, and not only reformed the health system but I brought results.
The third [reason I seek this position] is the political and diplomatic and technical know-how that I have. I think that WHO needs a balance of these three, and the diplomatic I can give you one example. The basis for the financing of the Sustainable Development Goals is the finance for development. That was already [agreed upon] in Addis Ababa in July 2015. I chaired the negotiation of the finance for development that resulted in the Addis Ababa action agenda.
It's a balance of technical and political intervention that can help WHO move forward. WHO is not just a technical organization. It needs political intervention too, and also a globalized leader. A balance between the technical, political and diplomatic skills is essential.
What do you think are the major challenges at WHO? What are the things that you would like to do differently?
I think reforming the organization is very important. It has to be reformed, and we need to have a very effective, efficient and transparent organization.
There should be a balance between reform and stability. When reforming, we have to focus on getting things done, also, because the world expects quick results, quick wins, and unless we really show [we are] getting things done, we cannot really insure the credibility of WHO.
What are the specific things that you think need to be reformed?
When you talk about reform, I will be open minded. You cannot just bring something and say, "I'll reform this." It will start from listening — listening to the facts, listening to the partners, to all member states, and [being] really clear about what should be reformed, and not only clarity on what should be reformed, but when we reform, everybody, all partners will be involved with it. All reforms start from clear listening, so that's what I will do. There should be an inclusive process in the identification of it.
In Ethiopia for instance we have started from assessing the situation. Even agreeing on the outcome of our studies in the areas that need reform, and then we needed to have a buy-in from the community. From the political leaders, from the national partners, from NGOs and civil society, and that's how we really had effective reform. And they were ready to put their choices, the community put their choices in, the government, the partners, and everybody.
That reform should really be inclusive, starting from the idea. It doesn't mean that I don't have a reform idea, but I wouldn't really preempt what the study or others may suggest. The fact is that reform starts from starting to listen from the very beginning. That the reform will cover many areas, it could be the problems, the government itself, financing, even the relationship between the management and the staff.
Financing is often cited as one of WHO’s greatest challenges. The incoming director-general is going to be very constrained in what they can do, because they will only control about 20 percent of the budget, and the rest is earmarked. What's your plan for dealing with that issue?
The member states do not own WHO with an assessed contribution of just 20 percent. It's a simple principle. If you have less than fifty percent of share in a company, you are not a majority share[holder]. So I asked the question during the candidate forum, do we realize that we don't own this organization, because we have only a share of 20 percent? We have to really commit to increase the assessed contribution. That's how you can ensure ownership at the minimal 51 percent. It's a very globally agreed principle that you have the company as a majority share holder. I think we should realize that we don't own it.
Without predictable and flexible financing, and most of it from a good contribution, I don't think it can do what's expected of it. But on the other hand, the confidence of member states is low at the moment, so that's why I'm asking for an increase in financing of the assessed contribution. We have to show some results also, quick wins that can increase or boost the confidence of member states. It should not be, “give me money” — you have to get things done and show some results for it.
What are the quick wins you're thinking about?
We cannot predict all epidemics, but we can prepare for it, so we can do better. So one of the vulnerabilities for WHO is what happened with Ebola for instance. The basics are the same: Early detection and also rapid response, so boosting the surveillance system, the communication between countries, and the honest implementation of the international health regulations.
There will be different priorities, and there are converging priorities also. I have outlined five. The number one is reform of WHO. The second is universal health coverage. That covers both communicable diseases and noncommunicable diseases, including mental health. The third is emergency response, starting from prevention, early detection, rapid response, with a robust government system. Number four is the focus on women, children, and adolescents, who in many countries are really marginalized. When you marginalize the majority of the population the impact of your intervention cannot be significant. Then number five is climate and environmental change.
Health [should be] at the center of the global development agenda, because it's a healthy society that can bring prosperity.
All roads lead to universal health coverage. Because universal health coverage means leaving no one behind. These communicable diseases, these non-communicable disease, these maternal health, injuries or aging. You don't leave anyone behind. Universal health coverage actually addresses even the demographic change. So universal health coverage is central. It's the center of gravity, and all roads should lead to that, and that should be the commitment of the whole world. Everybody understands it, the problem is we're not walking our talk. If that can be done, I think many of the health problems can be addressed. I think we should focus on that.
But the implementation is where these things become difficult. How has that worked in Ethiopia? I know that retaining medical staff has been a big problem.
We were wrong to really believe that brain drain is the root cause of the workforce crisis. We have to admit that the root cause of the problem is internal. We were not training enough based on the demand that we have. We increased the enrollment over two years from 300 to 3,000. We converted many of our major hospitals into teaching hospitals. Now we have started graduating more than 2,000 a year. Even if we lose to brain drain, we don't mind. So the root cause should be addressed, and that's how we addressed it in Ethiopia.
How do you deal with the issue of earmarking? For instance, in Ethiopia I know that the vast majority of the funding from the U.S. was supposed to be toward HIV/AIDS.
What we did was we started negotiating with U.S. government officials. We say to them, you know, focusing on one specific disease is very important because it’s a major problem, but at the same time if we don't invest in the health systems now, we cannot prepare the health system to be ready to fight for the future. So we asked them to invest in the health system. We were able to invest in building brand new systems for health information management, pharmaceuticals, hospital management and health care finance.
One of the problems is we don't see the health system as a whole. We see it as a silo. Malaria, HIV, TB, okay that's important, these are the specific parts, but we need to see the system also. In Ethiopia, health care reform was financed by PEPFAR and the Global Fund and also other partners such as the U.K. Department for International Development and other major partners, and now it's a very strong health system. The negotiation really went well. We helped them see the benefits of investing in the health system.
What do you think are the main lessons for WHO from Ebola?
I think from Ebola, we need to look for the instruments we have at hand already. There were problems in Liberia, Guinea and Sierra Leone, and then it was better managed in Nigeria. It was well managed in Nigeria because the polio system they have. You know the early detection and so on. So instead of reinventing the wheel, I think the world can really look for the tools at hand. I'm not saying the polio system can be revamped for all these epidemic problems, but it can help like it did with Ebola and while using that we can look for other tools..
Ethiopia's gotten a lot of criticism on human rights issues. Now that you are trying for this international position, how do you respond to those concerns?
Our government is committed to democracy, human rights, you know, all of it. We recognize democracy as a process. No country, even a country with a very mature democracy, reached wherever it is overnight. It actually matures from inside. It cannot be prescribed. [Ethiopia] is a nascent democracy, which is under construction, so it will have flaws. It's a process. It's not like all or none.
Sam Loewenberg is a journalist who covers the intersection of global health, business, government and politics. He has done research on global health and public policy at Harvard University as a fellow at the Nieman Foundation and at the Safra Center for Ethics, and at Columbia as a Knight-Bagehot fellow. His work has appeared in The Economist, The New York Times, The Washington Post, Foreign Affairs, Scientific American, Health Affairs, Playboy, and The Lancet, as well as on PBS. His website is www.samloewenberg.com.
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