“This race will be intense”: a look at elections for Director General of the WHO

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Grace Fletcher

Grace Fletcher

Grace Fletcher is a candidate for the MPH in Global Health & MA in Latin American Studies at Vanderbilt University. She works at the intersection of social science and global health and is interested in research, M&E, and program improvement, especially in marginalized Latin American communities. She is the Editor of the Global Health Hub. @grfletcher07

This week, the World Health Assembly is meeting in Geneva. Elections for the next Director General of the World Health Organization is a top item on the agenda. Liana Rosenkrantz Woskie, an author of a recently published article in the BMJ that outlines questions the world should be asking candidates for that position, joined us for a brief chat.

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Liana Rosenkrantz Woskie is the Assistant Director of the Harvard Initiative on Global Health Quality. Prior to her current role at Harvard, Liana studied insurance continuity with the Center for Medicare and Medicaid Services and was a Global Health Corps Fellow at Partner’s In Health’s PACT Project.  Interested in governments’ role in delivering patient-centered care, Liana traveled to over 10 countries studying iterations of the CHW model. Since joining Dr. Ashish Jha’s research team, she has worked to launch the Initiative on Global Health Quality (HIGHQ), an effort to design and evaluate health policies that improve care quality at the regional and national levels. More recently, Liana became the Harvard Global Health Institute’s point person on Global Response to Pandemics programming. As such, Liana has managed the Institute’s edX course on Ebola as well as projects on WHO reform and financing. Liana holds a BA from Wesleyan University and completed graduate studies at LSE and LSHTM.

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The member states of the World Health Organization (WHO) will meet to discuss electing a new director general at the World Health Assembly in Geneva this week. How does that process work?

While potential candidates have been positioning themselves for a while, the WHO election is only now appearing on the public’s radar. A year from now, the World Health Assembly (the forum through which the WHO is governed) will be asked to vote on a new Director General (DG) of the WHO. Candidates are beginning to surface and rumors on how this cycle will pan out are widespread. As you can imagine, this week’s WHA is particularly charged. Here’s a rough breakdown of the election timeline (it’s long):

  • September 22nd: Deadline for member states to put forward names of candidates
  • September 23rd: Names released formally (CVs & application materials to be made public)
  • January, 2017: WHO executive board to draw up a shortlist of up to five candidates and following interviews, will nominate up to three candidates for the final shortlist
  • May, 2017: Secret vote on finalists (at the WHA)
  • June 30th, 2017: Next DG to take office

To date, only a few people have announced that they’re running (Philippe Douste-Blazy of France, Tedros Adhanom Ghebreyesus of Ethiopia, and Sania Nishtar of Pakistan) and it’s important to keep in mind that candidates will not be formally announced until September, so there is a lot that we still don’t know. What we do know is that this election will be different than anything we’ve seen before. The last election was 10 years ago and much has changed since then. First, the Ebola and Zika epidemics both happened under the watch of the current DG and there hasn’t been an election since then. Second, completely apart from recent humanitarian emergencies, the election process has changed. This includes a 2012 effort to re-work the process to improve transparency and accountability as well as a 2015 shift in voting guidelines. A few things to watch:

  • For the first time, WHO member states will be able to vote. However, as Laurie Garrett has pointed out, there may be some issues on this front: “For the first time since it was founded in 1948, the WHO will select a new DG via a process that gives Niue, population of 1,612, an equal vote with China, population of 1.4 billion – and Lichtenstein, population 33,720, equal voting power with India, population 1.25 billion.”
  • A code of conduct for the election
  • An electronic forum that will be open to member states, not the public, who can pose questions to candidates in written form (starting October 24th)
  • A live forum, similar to the previous forum, which will be open to member states. Here, each candidate will make a presentation followed by a moderated Q&A session (November, date TBD)
  • The use of a new electronic voting system for nomination and appointment

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How do you think the intense media scrutiny of the WHO DG’s response to the Ebola epidemic will affect the vetting and election of the next DG?

There’s no question, this race will be intense.

I think the key point here is using this public attention to force a level of specificity that we haven’t really seen yet. While criticism of both Margaret Chan, the outgoing DG, and the WHO has been widespread, their responses have been bland and center on some variation of “WHO reform is underway.” It’s easy to hear this and move on; it sounds like progress is being made. But, if we’re being honest, WHO “reform” has been happening for a long time. What does that actually mean? Are reforms addressing fundamental concerns with the culture and purpose of the organization?

Similar to the UN Secretary General election, transparency has not been a key feature of the election process for the WHO, with a host of “under the table” factors playing into who is elected to the position. The 2012 and 2015 reforms attempted to bring more clarity to the process but it is, ultimately, still secret. In a time of public attention, what is clear is that as candidates emerge, the global community needs to call for a better and more substantive understanding of where these individuals stand on key issues and their vision for the organization moving forward. Our hope, in publically posing difficult questions throughout this election cycle, is to shake things up and add diversity and depth to the conversation. This builds on previous work by Richard Horton at the Lancet and others in previous elections.

You can see some key questions in our recent BMJ piece: “Facing Forward After Ebola: Questions for the Next Director-General of the World Health Organization.” These questions were informed by key thought leaders that evaluated the Ebola response and made suggestions for reform moving forward. We looked across reports to find areas of agreement, disagreement and more broadly, categories of concern. Each of the 15 questions draws on this body of work. Authors of the piece served on three of the major post-Ebola reports, which demonstrates a surprising degree of consensus on some of the key issues facing WHO.

This election cycle could be business as usual. Or, given the unique level of attention, it could be an opportunity to ensure we don’t repeat the failures of Ebola and recommendations are made actionable beyond a series of reports.

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Where do you see the WHO in 10 years?

It’s hard to say what the WHO will look like in 10 years. Clearly, the WHO needs to critically re-think its role. To be blunt: we have developed new non-WHO entities again and again when faced with real disaster. With AIDS, it was UNAIDS; with Ebola, UNMEER, etc. Even now, the World Bank’s Pandemic Emergency Financing Facility  again raises questions the WHO’s role. Sure, the WHO “helped design” the fund and they will be active in the process of identifying when funding should be allocated, but if this major pot of money sits at the Bank, what does this really mean for WHO? It certainly doesn’t read as a vote of confidence. The question is this: what is WHO uniquely positioned to do and, on the flip side, what should it not be doing?

A related issue that will hopefully receive attention over the course of the election, the new DG’s term, and the next 10 years is how WHO is financed. There is disagreement on this topic for obvious reasons. I’ve heard a lot of: “Yes, WHO’s response to Ebola was flawed, but the organization needs more money.” Many of my colleagues are not convinced, and I agree. While enacting significant reform does require funding in the short term, there are real issues with the status quo. WHO is financed through a mix of voluntary and “assessed” contributions. There is a great deal of nuance to this, but the quick and dirty version is that WHO has a fair amount of autonomy in the use of assessed contributions (20% of total budget), but there are strings attached with voluntary contributions (80% of total budget). What that means is national, or even organizational (e.g., Gates Foundation), priorities significantly shape WHO’s programming. It’s pretty tough to adhere to, let alone understand, your own mandate with a financing structure like that.

What I would say is this: at its core it’s not necessarily about more money, it’s about having the right money. For better or worse this requires strong leadership. My thinking on this has been significantly influenced over the course of the past year working with Peter Piot on the panel he chaired with our team at the Harvard Global Health Institute: Will Ebola Change the Game? Ten Essential Reforms Before the Next Pandemic. In his role as director of UNAIDS, Dr. Piot took a strong stance on how the organization was financed – actively refusing money that might compromise UNAIDS’ value as a global governance agency.

But there is a risk. Ashish Jha, the Director of the Harvard Global Health Institute, has said that relying on a charismatic leader is a bad long-term organizational strategy. And that rings true here. The next DG will need to take a strong stance on financing and a number of other issues, but it doesn’t stop there. We need redundancy built into the system, clear lines of responsibility, accountability, and a culture that allows for the candid discussion of what’s working and what’s not. Also, making sure we can respond when the next emergency hits should never be just one person’s job. As a global community, we can’t excuse ourselves from the responsibility. That means we have a role to play in ensuring our system works better and ultimately ensuring lives are not lost. In the short term, it means pushing for transparency, ensuring that reform is not superficial, and being active, in whatever ways we can, to inform a system we trust.