The new Director General (DG) of the World Health Organization (WHO) will soon be elected. If the upcoming election does not effectively hold to account all candidates, especially the successful one, the WHO risks losing its influence as the leading global public health authority.
On May 23, 2017, for the first time in WHO’s history, all 194 Member States of its governing body, the World Health Assembly, will cast a vote for the new WHO DG at its annual meeting in Geneva. (Previously, the DG was selected by the WHO's 34-member Executive Board.)
But, public health challenges are too great to allow the vote to descend into geo-political horse-trading and unchallenged controversy-dodging in an environment where opportunities for public vetting are few.
The WHO DG is head of a global staff of 7,000 and chief global ambassador to national health ministries world-wide. The WHO’s prominence and the need for its leadership in global public health have long been greatest in low- and middle-income countries where national health systems suffer a relative lack of financial resources and specialized technical expertise. But high-income countries draw on the WHO’s work, ranging from graded distillations of nutrition and alcohol research to annual advice about the best flu vaccine to administer globally.
The three candidates shortlisted for the position of DG have been persistently ambiguous about their stances on important governance issues. Perhaps they prefer to sidestep controversy as they court votes and financial contributions. Yet, since the future of WHO is neither secure nor clear, the office will ask courage and fortitude of the successful candidate. However, failure to elect the right candidate could spell 5-10 years of equivocation and capitulation. Media scrutiny of WHO DG candidates has been meagre. A global health writer for the New York Times reported that none of the candidates “will name any countries, foundations or corporations they think have too much influence.” Moreover, opportunities for civil society groups to publicly vet candidates and gauge their dedication to public health principles are as few as openings for non-profit groups (even those with Official Relations status at WHO) to meaningfully influence WHO governance between elections.
The intentions of candidates for addressing fundamental matters of health governance—especially discretion delegated by the World Health Assembly to the Director-General to revamp relations with non-state actors—matter a great deal. Likewise, candidates’ resolve to and success in achieving commitments made during the campaign should count.
The Code of Conduct for the Election of the Director-General of the World Health Organization stipulates that “Member States and candidates should refrain from improperly influencing the election process, by, for example, granting or accepting financial or other benefits as a quid pro quo for the support of a candidate, or by promising such benefits.” If, hypothetically, candidates ran afoul of these requirements or others in the Code, it is unclear what could be done to remediate them, at whose insistence, and by whose authority. Recent policy reforms respecting engagement with non-state actors remain so ambiguous that some might infer that collaboration with vested interests is now even de rigueur.
In May 2016, the World Health Assembly mandated that the Director-General should fully implement a new Framework of Engagement with Non-State Actors (FENSA) by May 2018. However, the details of the remit send mixed messages in, for example, stipulating conflict of interest safeguards while expressly allowing “Official Relations” status (a type of non-voting membership in the governing body) to be conferred on business interest associations for the first time since WHO’s inception. Likewise, the WHO has assiduously avoided expanding the list of industries (beyond the arms and tobacco industries) from which it would not accept funding.
Weaknesses in the FENSA conflict of interest safeguards were exemplified by the fact and manner of admitting the Bill and Melinda Gates Foundation into Official Relations Status in January 2017, even before the application handbook had been published. An open-letter, signed by four dozen civil society experts - expressing concern that the Gates Foundation Trust is invested to the tune of billions of dollars in soft drink, fast food, grocery, pharmaceutical drug, and television cellular phone technology companies, whose products are widely considered to contribute substantially to public health (either as problem or remedy) - was circulated to the WHO’s Executive Board meeting in January 2017. The Gates Foundation funded the WHO to the tune of about $629 million in the organisation’s biennial 2016-2017 budget, which makes the Foundation the second most important donor after the Government of the United States. A statement of continuing concern about commercial influence of the WHO was endorsed by 61 health groups, distributed to the three candidates, and published recently in The Lancet. (At the time of writing at least two candidates responses were published in The Lancet or in press.)
Since the founding of the WHO shortly after World War II, nongovernmental organizations have been invited to enter into “official relations” with the WHO. However, involvement of NGOs in the governance of WHO is still generally confined to making brief oral comments after decisions are taken by voting members at Executive Board and Assembly meetings, even if the contributors are experts in their fields. All-important negotiations—including the FENSA negotiations—are routinely conducted in, ironically named, “open” meetings of member States which are held in camera and from which media and NGOs are expressly excluded. But expressly allowing business interest associations into the fold in this way seems to hollow-out the distinction between the governance role and those parties who might influence it, and it seems directly contrary to the rationale for conflict of interest safeguards.
Ensuring more robust conflict of interest safeguards, and creating more meaningful roles in governance for public interest organizations, are necessary procedural reforms but they are not sufficient to help the WHO realize its important potential or safeguard its important mandate. In recent weeks, 39 health and citizens’ groups elaborated and endorsed a joint-statement entitled “The WHO we want and the leadership WHO needs” stressing, among other things, the need for:
- a human rights based approach to health governance,
- a health-in-all-policies approach (that is, recognizing that the responsibility for health lies not solely with traditional health ministries),
- reviving treaty-making authorities conferred on the WHO by its Constitution, but brought into force only once since 1948 (for the Framework Convention on Tobacco Control),
- ensuring that health is not subservient to economics in international trade disputes, and
- resolving tensions between developing countries that need WHO most and wealthy countries that provide the lion’s share of its operating budget (and house bigger headquarters of food, alcohol, pharmaceutical, and other companies) in a principled, public health based manner.
The stewardship of the World Health Organization nominally rests in the hands of 194 part-time overseers, many of which are perennially reticent to fund the WHO’s operations adequately, leaving the WHO to rely on voluntarily funded projects that are tantamount to ‘outsourcing’, and yet keen to heap chronically ambitious work plans on WHO staff.
We need to know more now about the Director-General candidates’ plans for their tenure in office, especially on the tough questions like these.