The World Health Assembly’s election of Tedros Adhanom Ghebreyesus to serve as its 9th Director-General may be the most momentous in the Organization’s 70 years for reasons far beyond electing the first African. The World Health Organization (WHO) faces a crisis in confidence following its anemic response to Ebola. It remains caught in an unvirtuous cycle: Member State loss of trust results in a paucity of funding and the continual inability to perform. This is a moment to take stock of the new Director-General’s record and vision, as well as the reforms needed to transform WHO into the 21st century institution the world sorely needs.
The Director-General’s Record
Dr. Tedros’s record reflects a contrast between high hopes and genuine concerns. As Health Minister, he transformed the Ethiopian health system. The Health Extension Program created more than 35,000 community health workers. He pioneered health worker training, with a tenfold increase in medical school enrollment. Few African countries kept the Abuja Declaration pledge to devote 15 percent of their budget to health. But Ethiopia exceeded that financing target. He also secured significant international financing, with 41 percent of Ethiopia’s health expenditures coming from foreign assistance in 2012, his last year as health minister.
Ethiopia achieved stunning success in child mortality and maternal mortality under his stewardship, with approximately 60 percent reductions from 2000 to 2015. Consequently, Ethiopia achieved the Millennium Development Goal on child mortality, nearly also achieving the MDG maternal mortality target. Bill Gates called improved child survival “Ethiopia’s revolution,” which “blows my mind,” and here is why.
Yet Dr. Tedros was also special advisor to the prime minister and served on the ruling party’s central committee in a repressive government. Human Rights Watch reported widespread torture, disappearances, and repression of the media and civil society. The government also failed to declare several cholera epidemics, despite United Nations confirmation. Calling the disease “watery diarrhea,” the government did not accurately report to WHO as required by the International Health Regulations.
Now that Dr. Tedros represents the community of nations, his condemnation of human rights abuses and defense of International Health Regulations norms would be transformative. His first words as Director-General were inspiring, “all roads lead to universal health coverage.” Every person has the right to a healthy life.
A 21st Century WHO
Empowering a 21st century WHO, fit for purpose, should be among the world’s highest priorities. Here are five building blocks for a reinvigorated WHO.
1. Sustainable Financing
WHO’s most glaring problem is financial unsustainability, with resources wholly incommensurate with its worldwide mandate. WHO’s 2016/17 budget is $4.385 billion — less than a large US hospital. Even this bare-bones budget doesn’t reflect the agency’s fiscal weakness. A single campaign—polio eradication—takes up nearly one-quarter of its budget. In October 2016, Margaret Chan reported a $500 million deficit.
Reflecting Member States’ stubborn refusal to fund WHO, India inexplicably rejected Dr. Chan’s proposed 10 percent rise in assessed dues, claiming a $342,000 increase was “unaffordable.” At the May 2017 World Health Assembly, Member States approved a meager 3 percent increase. The “new normal” finds WHO competing in an over-crowded humanitarian landscape. Even worse, the Director-General has little control over nearly 80 percent of his budget, as donors frequently earmark voluntary funds for their pet projects. It is past time for Member States to act as stakeholders invested in WHO’s success.
Dr. Tedros should convene a sustainable financing dialogue to create a five-year plan for sustainable funding, including mandatory assessments and innovative financing. Models include UNITAID’s “solidarity” levy on airline tickets and/or an international financial transactions tax. Several countries are considering an airline ticket levy, while Norway allocates part of its tax on carbon dioxide emissions to UNITAID. Governments might also consider donating part of their “health taxes” (e.g., on tobacco, alcohol, or sugar) to fund WHO.
2. Inclusive participation
Private/public partnerships such as the Global Fund and GAVI Alliance include civil society as full partners. UNAIDS affords affected communities a powerful voice, albeit with non-voting board status. WHO, however, remains stuck in state-centric governance. This is a missed opportunity, as civil society can bring fresh ideas, become potent advocates for WHO, give voice to marginalized communities, and hold powerful actors—and WHO itself—accountable.
WHO’s new Framework for Engagement with Non-State Actors focuses on managing conflicts of interest, doing little to change the basic governance structure. WHO requires non-governmental organizations (NGOs) to qualify for “official relations,” which most lower-income country groups can never achieve because they must demonstrate international scope or membership. Even NGOs in “official relations” have limited opportunities for genuine input.
WHO governance sharply contrasts with human rights norms, including community participation in health-related decision-making. Dr. Tedros should convene a NGO and community forum, with outputs including participatory governance and ongoing high-level engagement of civil society leaders. Participatory governance could be broadened through regional and local hearings as well as web-based input.
3. Multi-sector engagement
Nearly a decade ago, the Commission on the Social Determinants of Health observed, “the high burden of illness responsible for appalling premature loss of life arises … because of the conditions in which people are born, grow, live, work, and age.” Yet, this socioeconomic agenda remains on WHO’s margins, garnering <1 percent of the Organization’s budget. Dr. Tedros should create a social determinants department, while diversifying staff competencies to include anthropologists, social scientists, economists, and engineers. He should work closely with ministers from multiple sectors, including the environment, finance, water, sanitation, education, and agriculture. Strong advocacy for “Health in All Policies” or “All of Government” strategies would ensure “joined up” policies at the national and local levels.
WHO should also deepen engagement with multilateral institutions, including human rights treaty bodies. Treaty bodies such as the Human Rights Committee and the Committee on Economic, Social, and Cultural Rights—which monitor the two major international covenants of human rights—would enable WHO to more vigorously defend the right to health. Engagement with the World Trade Organization, World Bank, and International Monetary Fund would make it easier for WHO to influence decisions that can have major impacts on health.
4. Good governance
External evaluations rank WHO low in effectiveness, organizational learning, transparency, and accountability. The UN Joint Inspection Unit review of 28 UN agencies found WHO “below average,” while the One-World Trust on WHO accountability found “large scope for improvement.” The United Kingdom evaluated WHO organizational strength as merely “adequate.”
Dr. Tedros should introduce real-time performance monitoring to promptly correct course, while also authorizing annual, multi-stakeholder assessments of performance. The process and results must be transparent, and the Organization must act, and be seen to act, on objective evidence. Under-performing staff must be held accountable.
As WHO focuses on Secretariat governance, just as important is Member State accountability. States must contribute fully to WHO budgets, while implementing WHO plans of action, strategies, codes, and other WHA resolutions. Dr. Tedros should establish an accountability framework, beginning with state self-assessments and WHO’s own data, and moving towards independent external evaluations, with results listed publicly by country.
5. Normative leadership
WHO’s normative functions are central to its position as the world’s leading health authority: setting standards, promulgating regulations, and negotiating treaties. Despite its extensive normative powers, WHO has negotiated only two major treaties in seven decades. Yet WHO has myriad opportunities to create transformative norms: technical guidance on climate change and health; norms for integrated, people-centered health services; national equity strategies and rights-based benchmarks; health financing targets and pathways; and right to health impact assessments.
The success of WHO’s Framework Convention on Tobacco Control has spurred advocacy for further treaties, such as on alcoholic beverages, noncommunicable diseases, access to medicines, and antimicrobial resistance. Even more boldly, Dr. Tedros could begin negotiation on a transformative human rights treaty such as the Framework Convention on Global Health to achieve greater equity, participation, multi-sector engagement, financing, and accountability.
Guided by an unyielding insistence upon and institutionalization of human rights, demanding and developing mechanisms for WHO Secretariat and Member State accountability, and unwavering commitment to the public’s health over politics, Dr. Tedros could return WHO to global health leadership. Too much is at stake for him to do otherwise, while states and stakeholders must do everything possible to make his tenure a historic success.
