The Election of the Next World Health Organization Director-General Explained to a Visitor From Mars

In less than a year, the World Health Organization (WHO) will have a new director-general. The highest global public health job will go to a person nominated by a country or a group of countries and “elected” in a secret vote by the representatives of the 194 member states of the WHO. A visitor arriving from Mars would probably find this process strange: the most demanding position in global health, in technical and managerial terms, will go to the best politically connected applicant.

The process of selection is presented as transparent, thanks to new procedures, such as the adoption of a code of conduct for candidates and their supporters, and open discussions of the “program” of the candidates who will make the short list. In the end, however, each member state will vote secretly, which opens the door to behind-the-door negotiations and deal-making. Our alien visitor also may find it odd that candidates are invited to express their “vision of priorities and strategies for the WHO,” when one would expect the WHO to define a mandate and ask candidates to show their capacity to fulfill it.

A LEADING TECHNICAL AGENCY

Can such a process lead to giving WHO the capacity to become what it should be: the leading technical agency that coordinates global health interventions and proactively sets the agenda? Like many other observers, I think that the present governance process of WHO makes the achievement of its mission almost impossible. An organization divided into seven regional components whose leaders are elected and therefore accountable to those who supported them rather than to a central authority cannot be the effective and efficient organization that the world needs. What is required is a real technical agency, led by a team of individuals with established public health and managerial competencies, not careerists, with the credibility to mobilize the other stakeholders—namely, the member states themselves, other United Nations agencies, development banks, and major nongovernmental organizations—and to play the role of coordinator, which is much needed to avoid duplication and even contradiction of different global health interventions.

Recruitment at all levels should be on merit, irrespective of criteria such as representation of different sectors and areas of the world or political expediency; professionals could then work without political pressure. The current intense campaigning for the top job would be avoided. An independent high-level management team would facilitate that WHO works as one organization and that internally its various directorates and departments be exemplary in coordinating their activities. It would be strong on horizon scanning, on providing timely advice, and on supporting the implementation of good practices. To say that WHO should become less political does not mean that it would not be accountable for its actions; why not make it report directly to the United Nations Assembly?

HEALTH SYSTEM STRENGTHENING AND HEALTH WORKFORCE

It is too much to expect that such changes will happen under the next director-general, irrespective of who will occupy the position; recognizing what little reform has been accomplished since the process started 10 years ago is enough to limit expectations. This does not mean that nothing can be done.

An area in which WHO has been a vocal advocate but a poor performer is that of “health systems strengthening.” Much has been written about the need for better-performing health systems after the Ebola outbreak, but it had already been clear for many years that this need should be a top priority, as shown by the difficulty so many countries faced in achieving the Millennium Development Goals, let alone universal health coverage. Yet WHO has not invested its energy in developing its internal capacities to support countries in making their health systems more sustainable and ready to address current and emerging needs.

One particular neglected area is that of the health workforce, without which no system can respond to its population’s needs and expectations. In 2006, WHO declared that the next decade would be that of human resources for health. Much was indeed accomplished, with very limited and in some cases declining resources. After 2006, the number of staff working on health workforce issues diminished in WHO headquarters in Geneva, Switzerland, and in the regional offices; in Geneva, the relevant department was without a director for almost two years. Linkages between regional and headquarters staff were not formalized, and opportunities for cross-fertilization were missed.

As a result, other organizations (in particular, the World Bank) took the lead in the development of the basic analytical work and in supporting policy development at the country level. A new director-general would do well in strengthening WHO’s departments of health systems and health workforce and in ensuring that they work in a coordinated manner. The headquarters team, which has developed a global strategy on human resources for health,¹ has set ambitious and far-reaching objectives that will require more resources than currently available. Such a strategy also requires buy-in at the level of regional offices, which are closer to countries and better positioned to influence and support the health workforce and health system strengthening. To go beyond the provision of advice and actively support the implementation of change, regional offices also need to devote more resources to that process, as well as develop technical capacity in change management. A new WHO should draw lessons from its most important success, the eradication of smallpox, which was primarily the result of competent and imaginative management.²

WALKING THE TALK

What can public health associations do to help WHO become the “Global Guardian of Public Health” it declares to be? They can come together and define the profile of a global organization capable of responding to current and future health challenges. They can join forces in advocating at global level for a reformed WHO. At national level, they can lobby their governments and pressure them to initiate the change process. The United States, the European Union, Japan, Canada, and Brazil, where strong public health associations are active, have enough of a voice to trigger change if political willingness to do so exists. All these countries adopted the United Nations General Assembly Declaration on Global Health and Foreign Policy (December 12, 2012) committing them to implement universal health coverage and the Sustainable Development Goals: if they are true to these commitments, they should walk the talk and take the lead in building the global health agency the world needs.