Q&A: Former MSF president on the WHO leadership race

Later this month, member countries of the World Health Organization will vote to elect a new director-general. All three finalists — Dr. Tedros Adhanom Ghebreyesus from Ethiopia, Dr. David Nabarro from the United Kingdom, and Dr. Sania Nishtar from Pakistan — have vowed to pursue the reforms engaged by the organization in recent years. All three have expressed their intention to place transparency and accountability, emergency preparedness and response, and restoring the WHO’s primacy as the world’s leading health agency at the core of their mandate.

For Dr. Unni Karunakara, a senior fellow at the Jackson Institute for Global Affairs at Yale University and former international president of Médecins Sans Frontières, reform begins with recentering the WHO’s activities around its norm-setting mission.

“In a globally interconnected world, we need an organization with the mandate of WHO to be able to kind of set global norms and standards,” said Karunakara during a conversation with Devex. A critic of the new Health Emergencies Programme, created by the agency in 2016 to develop its operational capacities, he urged the incoming WHO director-general to preserve its core activities and programs amid a difficult funding climate.

Below are more highlights from the conversation, edited for length and clarity.

The election of the WHO’s new director-general is only a few days away. What should the focus of the organization be under new leadership?

The WHO is historically a norm-setting organization, not an operational agency. Last year, the WHO created the Health Emergencies Programme to respond directly to emergencies, and I see several problems with that. First, the WHO is supposed to act as a coordinator of the health sector, but it now has to wear the two hats of coordinator and implementer. How can they coordinate their own implementation as well as the work of the other agencies that are also implementers? I think that is a step in the wrong direction for an organization whose mission is to develop standards and norms.

The second problem is how funding works. Governments used to give money to the WHO, and it was largely up to the WHO to make a decision on how to spend it. This meant that even programs that were not considered to be a priority for governments would be funded because the WHO had a better sense of what needed to be covered. But now, with earmarked funding, the notion of funding the WHO as an organization, as opposed to funding its programs, has changed. What will happen with the emergencies program is that more of the money will go into programs to fund emergencies such as the 2014-2016 Ebola outbreak, and the WHO’s norm-setting functions will get ignored.

Was it not necessary for the WHO to adapt to these new funding realities in order to to attract more earmarked funding?

In the current climate, it's not that there’s more money in the pot. What’s more likely to happen is that what money you have in the pot gets redirected. For example, the United States government had pledged close to $1.8 billion for Ebola response and preparedness. Then when the Zika outbreak happened, former U.S. President Obama redirected $510 million from the Ebola funds to the Zika response.

The WHO should be fighting for funding. For example, some very important departments are underfunded, for example the social determinants of health. And these very important departments are not getting funded because member countries don't think it's sexy enough, or important enough. My fear is that while the money will keep on flowing for emergencies like the Ebola response, the important work that needs to continue in the WHO will not get funded.

What actions would you suggest the WHO should take in order to strengthen its role in emergencies?

There are a couple of issues. First, they should bring in reform that strengthens their norm-setting functions, rather than start new programs that will take resources away from their core functions. Second, they have to work on improving the linkages between the WHO in Geneva and all of their regional offices. If they can focus on these things, they will be in a better position to respond appropriately to emergencies by recognizing an epidemic early on. This is part of the reason why the responses to the Ebola outbreak and the cholera outbreak in Haiti were so slow.

What the new director-general should be focusing on is reducing duplication, not just in the WHO, but vis-a-vis the United Nations system, as well as reinforcing the organization’s norm-setting functions, and try to regain the supremacy of the WHO in this domain because it has been losing its relevance for a long time. First it lost it to the World Bank, then to the Bill & Melinda Gates Foundation. So the only way they can regain their primacy in norm-setting and standard-setting is by focusing on these activities, cutting out more of the fat, so to speak, and maybe hand over certain activities to other U.N. agencies such as UNICEF, UNAIDS, UNFPA, and so on.

The Health Emergencies Programme was requested and voted for by member countries, specifically to give the WHO the means to provide a unified response for emergencies and address coordination issues. Doesn’t it give the program its legitimacy?

I can accept the fact that there should be some sort of unified response from the U.N. to epidemics or humanitarian crises of this kind, but I don't think it should be the WHO’s doing. I'm not discounting the lives of people lost in Ebola, but I don't think the WHO could have responded any better. They could have responded earlier, but I don't think having their own health program would have improved the response significantly. The answer to these challenges is not to set up the WHO’s own unified response mechanism. The answer should be to fix the dysfunction that exists.

The WHO has historic responsibilities, but as members demand more and more from the WHO, what happens is mission creep. The WHO may get bigger and bigger, but it’s not necessarily getting more results. The director-general should be able to say “no” sometimes — “no, this is not for us, because this is our historic mission.” And the way they can continue to be a relevant organization is to be really good at the norm-setting, standard-setting functions they have.

To learn more about Unni Karunakara and Yale’s Jackson Institute for Global Affairs click here.

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