Whither WHO? Our Global Health Leadership

Monday, 7th of November 2016

Elizabeth Fee. Whither WHO? Our Global Health Leadership. American Journal of Public Health: November 2016, Vol. 106, No. 11, pp. 1903-1904.

doi: 10.2105/AJPH.2016.303481

Accepted on: Sep 5, 2016

Whither WHO? Our Global Health Leadership

Elizabeth Fee, PhD

Elizabeth Fee is with the National Library of Medicine, National Institutes of Health, Bethesda, MD and is also an AJPH editor.

This article is best viewed at http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303481

Correspondence should be sent to Elizabeth Fee, National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894 (e-mail: feee@mail.nih.gov). Reprints can be ordered at http://www.ajph.orgby clicking the “Reprints” link.

The process to elect the next director-general of the World Health Organization (WHO) has already been under way for several months. The 194 member countries can nominate candidates; the formal voting takes place at the World Health Assembly meeting in Geneva, Switzerland, in May 2017, and the new director-general will take office in July. Past elections have been marked by wheeling and dealing, with different countries and regions favoring particular candidates who will, they calculate, best represent their interests.

A NEW ELECTORAL PROCESS

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In 2012, new guidelines were issued in an effort to promote “transparency and fairness” as well as “openness, dignity, equity, and good faith.”¹ Whereas the 34 members of the Executive Board used to nominate a single candidate whom the World Health Assembly was expected to endorse, it will now nominate three candidates, chosen by secret ballot, and the members of the World Health Assembly will then be able to select the winner. First, each leading candidate will present his or her vision of the future of WHO and answer questions posed by any of the member states.

Within WHO, some countries and regions have called for geographical rotation so that each area of the world will, by turn, be able to nominate the next director-general. Others have argued that such a system could override the more important considerations of expertise and experience. A Japanese member of the Executive Board rightly commented that this position was insulting to the three out of six regions—Africa, the Eastern Mediterranean, and the Western Pacific—whose candidates have never been chosen for WHO’s top position.² Clearly, the election of the director-general can be contentious as well as competitive.

A STEWARD OF INTERNATIONAL ACTION

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For this issue of the AJPH, several prominent people, with long experience in international health, were invited to submit editorial statements, each giving a personal view of the coming election and the issues a new director-general will need to confront. This continues a practice, begun in 1998, of highlighting a series of positions on the WHO election. In the previous case, the editorials marked the election of Gro Harlem Brundtland, previously minister of the environment and prime minister of Norway. Mervyn Susser wrote that she would bring “fresh thought, imagination, competence, and commitment” to the task of leading the organization “back into its historic position of international leadership.”³^(p727) It seems that expectations for future director-generals are always high, and the agency is frequently in the process of being reformed.

Now, in 2016, Derek Yach (p1904) revisits the issue of WHO reform and argues that past reform efforts have not yielded the expected results. He suggests a continuing tension over the key purpose and functions of WHO: should it be an organization to set standards, conduct and coordinate research, and serve as a powerful voice for health in development debates, or should it be an organization to respond to epidemics, control diseases, and improve health systems? In popular perception and expectation, WHO is generally seen as the latter. Yach argues that WHO is best positioned to be the former, a normative institution, and should leave the job of responding to disease epidemics and public health crises to other organizations. These, he says, can undertake the work equally—or more—effectively.

Julio Frenk (p1906) agrees that reform is needed but asserts that the most important issues are finances and governance. The financial problem is serious: some states simply fail to pay their assessed contributions and others are reluctant to pay their fair share. As a result, WHO has come to rely on money provided by global foundations, development banks, and multinational corporations. These now dominate the budget and, inevitably, can thus set the priorities. Frenk argues that the next director-general must reorganize WHO by its core functions and focus on being the steward of international action for global health, leaving member countries, development agencies, and nongovernmental organizations to do the work for which they are best suited. On this point Frenk’s argument is similar to that of Yach. In terms of governance, Frenk contends that elections should be public and not the subject of secret ballots that can more easily be manipulated. The selection of the next director-general, he says, is crucial.

A SIMPLIFIED STRUCTURE

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Ariel Pablos-Mendez and Susanna Baker (p1907) argue that WHO must have “one clear line of authority, one workforce, one budget, one set of rules and processes, and one set of standard performance metrics.” In a new world populated by a multiplicity of global public health actors, the new director-general will need to have inspiring leadership qualities, noted management abilities, and the strong communication and diplomatic skills necessary for negotiating among and between member countries and competing agencies and interests—a tall order, perhaps, for an individual who must also have extensive national and international public health experience, be committed to evidence-based performance, emphasize access for all people to quality health care, and embody the values of equity and social justice.

Gilles Dussault (p1908) tries to explain the election of WHO’s director-general to a visitor from Mars who is expected to find the whole procedure rather peculiar. Dussault argues that the governance structure of WHO makes it almost impossible to achieve its mission. When regional leaders are elected, they are accountable to those who support them rather than to a central authority. This fragmented structure of WHO makes the job of the director-general extremely difficult. Adding to the problem of attempting to coordinate the public health activities of regions and member states is the need to coordinate the work of other United Nations agencies as well as a proliferating number of stakeholders—development banks, foundations, multinational corporations, and nongovernmental organizations—all seeking to address and influence the health status and public health programs of the world’s population. Dussault also emphasizes the need to help countries establish effective and sustainable health systems and strengthen the health workforce. He urges regional offices to develop their technical capacity and sound management practices.

BACK TO THE ROOTS

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Suwit Wibulpolprasert and Mushtaque Chowdhury (p1910) ask the dramatic question: should WHO be overhauled or dismantled? They outline many of the most notable successes and failures of WHO—as seen especially from the country perspectives of Thailand and Bangladesh—and again raise the problem of WHO’s financial dependency on outside donors. A new director-general, they assert, must demand more country contributions and ensure exemplary financial management. Furthermore, they suggest abolishing regional offices to save money and claim this would result in no loss of efficiency. By eliminating one layer of bureaucracy, member countries could thus interact directly with the Geneva headquarters.

The regional structure of WHO has been a significant source of debate from the organization’s beginning in 1948 and is the subject of a historical analysis by Fee et al. (p1912). They trace the changing political context of WHO, especially during the early years of the Cold War, when the organization’s basic structure was established, and later, the transformation of the European colonies into independent nations. It may well be time to revisit this form of organization, in addition to the issues of finance and management that the several editorials have so vividly presented.

REFERENCES

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1.	World Health Organization. News release: process to elect next director-general of WHO begins. Available at: http://www.who.int/mediacentre/news/releases/2016/election-process/en. Accessed August 30, 2016.
2.	Intellectual Property Watch. New rules eyed for election of WHO director general. Available at: http://www.ip-watch.org/2011/01/18/new-rules-eyed-for-election-of-who-director-general. Accessed August 30, 2016.
3.	M Susser. Editor’s note: a new director for WHO. Am J Public Health. 1998;88(5):727. [Abstract]