No African has led the WHO in its nearly 70-year history. As the world awaits the election of a new director-general in May, many experts are rooting for the African candidate. But will the coming election truly break the global health agency’s African-leadership glass ceiling?
When the World Health Organization’s 194 member states convene in Geneva in May for the global health agency’s annual general meeting, the World Health Assembly, one of three candidates shortlisted by the Executive Board on January 25 will be elected to succeed Dr. Margaret Chan as the eighth director-general of the agency.
Chan’s second term of office ends June 30. By law, directors-general can only serve two five-year terms. Chan, China’s nomination for the job, served a little longer because her predecessor, J.W. Lee of South Korea, died before his term ended.
Last September, six candidates were nominated for the position by the WHO member states – four Europeans, one African, and one South Asian.
Out of this list, Dr. Tedros Adhanom Ghebreyesus from Ethiopia, Dr. Sania Nishtar from Pakistan, and Dr. David Nabarro from Britain have made the final shortlist.
Dr. Flavia Bustreo of Italy, a WHO assistant director-general, and France’s Dr. Philippe Douste-Blazy were knocked out at the January 25 voting. Dr. Miklós Szócska of Hungary had been dropped earlier on January 24 to bring the number of contenders to five. Below are the three candidates.
Tedros Ghebreyesus; age: 51
Dr. Ghebreyesus is the only non-physician among the candidates. He completed his undergraduate studies in Biology at Asmara University in 1986, obtained a Master of Science degree in Immunology of Infectious Diseases from the University of London in 1992, and holds a PhD in Community Health from the University of Nottingham in 2000.
Over three decades, Dr. Ghebreyesus has been a distinguished leader who has saved and improved lives in Africa and around the world. A globally recognised expert and author on health issues, including health workforce strengthening, emergency responses to epidemics, and malaria, he has been co-chair, Partnership for Maternal, Newborn and Child Health Board, chair, Roll Back Malaria Partnership Board, chair, Global Fund to Fights AIDS, Tuberculosis and Malaria Board, Ethiopia’s minister of health as well as minister of foreign affairs.
An entry on him on Wikipedia says that as head of the Tigray Regional Health Bureau from 2001, Dr. Ghebreyesus was credited with making a 22.3 percent reduction in AIDS prevalence in the region, and a 68.5 percent reduction in meningitis cases; oversaw a campaign to improve ICT access that installed computers and internet connectivity to most of the region’s hospitals and clinics, whereas they had not been connected before; increased health care staffing by 50 percent; raised immunization for measles to 98 percent of all children and total immunisation for all children under 12 months to 74 percent; increased the percentage of government funding for the Tigray Regional Health Bureau to 65 percent, with foreign donors’ percentage falling to 35 percent; and overall, provided health care services within 10 km for 68.5 percent of the population.
His reforms as health minister transformed Ethiopia’s health system to expand quality care and access to tens of millions of Ethiopians, while in the global context he helped key global actors like The Global Fund and the Roll Back Malaria Partnership operate with greater efficiency and effectiveness.
In his vision statement, Dr. Ghebreyesus says he envisions a world in which everyone can lead healthy and productive lives, regardless of who they are or where they live.
“I believe the global commitment to sustainable development – enshrined in the Sustainable Development Goals – offers a unique opportunity to address the social, economic and political determinants of health and improve the health and wellbeing of people everywhere,” he says.
“Achieving this vision will require a strong, effective WHO that is able to meet emerging challenges and achieve the health objectives of the Sustainable Development Goals. It will require revitalised WHO leadership that combines the public health, diplomatic and political expertise needed to address the most pressing challenges of our time.”
Sania Nishtar; age: 53
Dr. Sania Nishtar, the sole female candidate, graduated from Khyber Medical College in 1986 and was Best Graduate of the Year. She holds a Fellowship of the Royal College of Physicians and a PhD from King’s College London.
An entry on her on www.who.int says Dr. Nishtar is the founder and president of Heartfile, which began in Pakistan in 1999 as a health information-focused nongovernmental organization and evolved into a think-tank on health policy issues. She is also founder of Heartfile Health Financing, a programme that uses a customized IT platform and mobile phones to protect poor patients from medical impoverishment or foregoing health care.
“Widely considered a thought leader on health policy, she has been a key drafter of several global health declarations. Dr Nishtar served in Pakistan during the 2013 caretaker government as Minister for Science and Technology, Education and Trainings and Information Technology and Telecom. During her term, she was instrumental in establishing Pakistan’s Ministry of Health,” the entry says.
She also founded Pakistan’s Health Policy Forum, a civil society policy platform for health experts that has garnered contributions from prominent global health advocates including Seth Berkley, Sir George Alleyne, Mark Dybul, and Naresh Trehan, in addition to many others
On the global stage, Dr. Nishtar has been involved with many international agencies in various capacities, including the WHO, the Alliance for Health Policy and Systems Research, the Global Agenda Council of the World Economic Forum, the Health Global Challenge initiative, among others. She is acclaimed to have extensive experience both nationally and internationally in the civil society sector.
David Nabarro; age: 67
Dr. Nabarro, who studied at University of Oxford and University of London and qualified as a physician in 1973, has spent much of his career in the WHO and the United Nations.
An entry on him on Wikipedia says he joined the WHO in January 1999, as project manager of Roll Back Malaria, then moved to the Office of the DG as Executive Director in March 2000. In this capacity, he worked with DG Gro Harlem Brundtland for two years on a variety of issues, including the Commission on Macroeconomics and Health, Health Systems Assessments and the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Dr. Nabarro transferred to the Sustainable Development and Healthy Environments cluster in 2003 and was appointed Representative of the DG for Health Action in Crises in July 2003. He has also coordinated support for health aspects of crisis response operations in Darfur, Sudan, and in countries affected by the 2004 Indian Ocean earthquake and Tsunami.
“I want to be sure that WHO is in a position to be the undisputed leader on all health issues. WHO must constantly strive for excellence in people’s health and health systems everywhere. WHO should, through its Member States and collaborating centres, nurture fullest attainment of people’s health in all communities. WHO’s performance should lead it to be recognized as the world’s specialized agency for health, earning and maintaining trust of governments, communities and people,” writes Dr. Nabarro on his personal website www.davidnabarro.info.
A member of the Faculty of Public Health (FPH) and the Royal College of Physicians by distinction, he is currently the special adviser to the UN secretary general on sustainable development and climate change.
The task ahead
Ed Whiting, director of policy and chief of staff at Wellcome, an independent global charitable foundation, has outlined several qualities the new director-general needs to have as well as actions the WHO must take to recapture the world’s confidence.
Recall that the WHO has faced a barrage of criticisms recently, especially following its slow response to the massive outbreak of Ebola in West Africa in 2014. There have since been calls for an overhaul of the agency, with particular emphasis on its emergency response capacity.
Whiting admits that despite its remarkable achievements, the WHO today is not fulfilling its mission, isn’t adequately funded for it, and is failing in its current form, but the arrival of a new director-general in a few months offers an opportunity for reform that the agency must put to good use.
He reckons that the WHO, as the only organization charged exclusively with speaking for public health and for health care workers around the world, needs more effective political leadership at this time to regain trust.
“At a time when health budgets around the world are under increasing pressure, the new director-general must strengthen the case for investing in improving health outcomes. That includes encouraging greater investment in stronger national health systems and epidemic preparedness, and being fearless in calling out countries that fail to take action where it is needed,” says Whiting.
The WHO, he says, must also strengthen its unique role in alerting the world to health emergencies and coordinating the responses to them. And while the WHO’s new emergencies team has shown that it can mobilize resources and action at a pace never seen in the organization’s history, the new DG, he says, needs to convince national leaders that the world doesn’t yet have the capability to respond to cross-border emergencies, making sure the WHO clearly sees the existing gaps and the steps needed to close them.
“The new director-general should also be fearless in calling out global health risks, such as the growth of artemisinin-resistant malaria in Southeast Asia, particularly where national and regional authorities are not doing enough to combat such threats,” he says.
He adds that the WHO must also lead the fight for access to innovative health care for all;
The new DG, he says, will need to work effectively with “the increasingly mixed economy of health care funders and providers” to ensure that the WHO has sufficient funds for its mission, as well as make a greater effort to better develop the WHO’s relationships with civic society and the private sector as every dollar invested by private companies reduces the burden on finance ministries and taxpayers and also delivers innovations and technical advances that can improve health. Whiting advocates an ambitious internal reform programme that simplifies the WHO’s complex governance structures, and challenging poor-performing offices at the national, regional, and global levels, contending that key to that would be ensuring that staff are selected for posts based on their competence, not their politics.
“Clear, decisive leadership on all of the above will go a long way to restoring confidence in the WHO — a vital prerequisite to attracting the financial support the organization so desperately needs,” he writes.
The politics
With the contenders narrowed down to three – one African, one Asian, and one European – the contest is no doubt at fever pitch.
At the January 25 voting, the presence of multiple Europeans on the ballot was seen as capable of splitting what would otherwise have been a significant bloc. Even Britain’s departure from the European Union was viewed as a minus for Nabarro, considered to be one of the strongest candidates on the grounds of experience.
Now that Dr. Nabarro is the only European left, analysts think his chances have been raised as he may benefit from the exit of Bustreo and Douste-Blazy. On October 21 last year, the UK government gave its formal backing to Dr. Nabarro.
Many pundits believe that the chances are high for Dr. Ghebreyesus, the African candidate, who has the support of the African Union, potentially a bloc of 54 votes at the World Health Assembly.
According to Helen Branswell, STAT’s infectious diseases and public health reporter, the word in international circles for a while was that it was Africa’s turn. No African has led the agency in its almost 70-year history. A number of potential African candidates tested the waters early on but did not go far. With the sole African candidate now in the final voting stage, optimism on his possible success is on the rise.
Pundits are relatively silent on the chances of Dr. Nishtar, the only female contender, who is equally eminently qualified for the WHO top job.
But more intriguing in the entire process is the secrecy with which countries have been guarding the direction of their voting. Countries have indeed been holding their cards close to their vests on this election, writes Branswell.
For instance, she says, Dr. Tom Frieden, the US representative on the executive board, who was until recently the director of the Centers for Disease Control and Prevention, would not reveal whom he’d been instructed to support.
“Even if countries had declared their preferences, the voting process would have made it hard to predict the outcome,” writes Branswell.
“In Wednesday’s voting, each representative voted for three people. The system may have been devised to try to ensure that the three strongest candidates made it to the final round. But observers predicted lots of strategic voting, with countries shoring up their favorites’ chances by using their second and third votes to support candidates who are perceived to be weaker than the rest,” she writes.
Observers are, however, keeping their fingers crossed.
Dr. Jeremy Farrar, director of the Wellcome Trust, hopes that more will be heard from the shortlisted candidates about how they will provide the direly needed inspirational leadership in the months remaining before the World Health Assembly in May.
Rooting for Ghebreyesus
Peter A. Singer, chief executive officer of Grand Challenges Canada, and Jill W. Sheffield, an independent consultant and long-time advocate for women’s health and rights, are rooting for Dr. Ghebreyesus, not just because they believe it is time to break the WHO’s African-leadership glass ceiling, but essentially because Ghebreyesus’ direct experience working in developing countries makes him uniquely qualified – indeed, “most qualified” – to tackle the world’s toughest global health problems.
They base their argument on “three considerations that are important in any hiring process, and especially for a position such as this: the candidate’s past achievements, leadership style, and the diversity that he or she brings to the table”.
“With respect to the first consideration, Ghebreyesus has a proven track record of success. As Ethiopia’s health minister from 2005 to 2012, he championed the interests of all of the country’s citizens, and strengthened primary-care services. He created 3,500 health centers and 16,000 health posts, and dramatically expanded the health-care workforce by building more medical schools and deploying more 38,000 community-based health extension workers,” write Singer and Sheffield in a recent article for Project Syndicate, “Breaking the WHO’s Glass Ceiling”.
They present Ghebreyesus as a long-time champion and advocate of gender equality and the rights of women and girls whose efforts to strengthen Ethiopia’s health system played a crucial role in more than doubling the percentage of Ethiopian women with access to contraception, and in reducing maternal mortality by 75 percent.
His efforts, they say, now serve as a model that other countries seek to emulate as they try to achieve universal health coverage for their citizens, adding that he is the only candidate who has achieved such results at a national level.
“When Ghebreyesus was Ethiopia’s foreign minister from 2012 to 2016, he gained extensive diplomatic experience, not least by leading negotiations for the Addis Ababa Action Agenda, the international community’s plan to finance the United Nations Sustainable Development Goals. This same knack for diplomacy is now needed to bring WHO member states together for cooperative action on collective health challenges,” they say.
They argue that his leadership style – he is a receptive listener but also decisive – is also perfectly suited for the role of WHO DG.
“He speaks last, and encourages others to share their views. He also knows how to spot and nurture talent, and how to bring the best out of the people around him. He would undoubtedly boost organizational morale and motivate the staff to deliver maximum value and efficiency – to the benefit of all member states and their citizens.”
Beyond these, Singer and Sheffield reckon that Ghebreyesus’ extensive leadership experience within global health institutions – as Board Chair of the Global Fund to Fight AIDS, Tuberculosis, and Malaria between 2009 and 2011, and as Chair of the Roll Back Malaria Partnership between 2007 and 2009 – count for much.
“Ghebreyesus pushed through sweeping changes that dramatically improved both organizations’ operations. What’s more, he helped them raise record-breaking financial commitments from donors: $11.7 billion for the Global Fund, and $3 billion for Roll Back Malaria,” they write.
“This is precisely the kind experience and expertise that the WHO needs in today’s global health environment, and it explains why the African Union has officially endorsed Ghebreyesus’s candidacy.”
Similarly, Prashant Yadav, a senior fellow at the William Davidson Institute at the University of Michigan and a visiting scholar at the Harvard Medical School, and Akash Goel, a physician, journalist, and a World Economic Forum Global Shaper, have also endorsed Dr. Ghebreyesus as the most qualified for the role in the current context of what the WHO needs the most.
They reckon that his suitability in his irrefutable ability to create and build efficient and sustainable health systems, the linchpin of health-care delivery, arguing that under his leadership, Ethiopia made such dramatic improvements in public health outcomes that it are often heralded as a model for health care delivery in low- and middle-income countries.
“During his tenure, Ethiopia trained and deployed nearly 40,000 health extension workers — mostly women — to the most remote and hardest-to-reach parts of the country to provide basic health care services. Evidence suggests that his interventions have led to precipitous declines in rates of infant mortality to levels that even countries with far more resources have not been able to achieve,” they contend in the article “The election that matters for the health of the world”.
Under his leadership, they write, Ethiopia, which had previously grappled with one of the greatest doctor shortages in the world, opened 13 new medical schools, dramatically increasing the number of graduating doctors in the country. He also created new partnership models to pair the new Ethiopian schools with leading U.S. and European institutions for faculty career development, curriculum enhancements, and capacity building for locally relevant research. This he did in order to douse concerns or critiques that opening new medical schools may lead to decrease in quality of medical education.
Coming to the political element to the role of director-general, Yadav and Goel argue that Ghebreyesus’ pragmatic and implementation-oriented managerial style and his political experience stand the best chance of convincing WHO member states to increase contributions to create a well-functioning WHO, at a time the agency is in dire need “fungibility or budgetary flexibility to act on emergent health issues”.
To buttress this point, the cite his achievement in Ethiopia, where he was able to convince government and private financiers that the overall system benefits when they let the country government act as a single point of control and coordination.
“The WHO urgently needs a leader to repair its deficit in finances and credibility. Fractured and under-resourced health systems are in need of fortification to not only project those within their own borders but also to build resilience against the rise of transnational threats to public health. Tedros is the candidate to do both, and it would be in all of our best interest to elect him,” they submit.
Will the best candidate win?
While many pundits think Ghebreyesus is the best candidate for the job, Branswell says that alone may not necessarily determine voting decisions.
“I would be highly skeptical that that is the driving force behind voting decisions. I think countries will vote based on strategic calculations,” she quotes Suerie Moon, director of research at the global health center of the Graduate Institute of International and Development Studies in Geneva, to have said.
For Branswell, voting for a position like this involves backroom diplomacy and often, frankly, horse-trading — “things that are impossible to track with secret ballots and when few if any countries openly declare their preference”.
With the election barely three months away, this may be the time for the African Union to reach out and engage in the backroom diplomacy and horse-trading needed to push its candidate through. Mere official endorsement may not be enough.
