Tedros Adhanom Ghebreyesus took office as the new Director-General of the World Health Organization in July. This change of leadership comes at a time when the organization is facing significant challenges.
Illustration: Ørjan Jensen/Superpop
The World Health Organization (WHO) is an independent UN specialised agency with 194 member countries. The organisation is governed democratically by the Executive Board and the World Health Assembly, which selects the Director-General based on nominations from the member states.
One of the World Health Organization’s strengths is its democratic structure, which is crucial in bringing member states together to address global public health problems and develop strategies and initiatives that transcend political dividing lines. The member states have different political and economic interests, but have nonetheless managed to reach agreement on many important public health issues, including international health regulations to prevent the spread of infection across national borders (1) and the Framework Convention on Tobacco Control (2).
Today, many countries that were previously dependent on the World Health Organization for technical assistance have gained competence in the fields of public health and medicine. However, they look to the organisation for the development of national guidelines. The WHO has a unique mandate to develop global norms and standards for health based on best practice and available knowledge. It also monitors and compiles health data and information that is collected in a separate database (Global Health Observatory) (3) and publishes global health statistics annually (4). All its publications are freely available online, meaning that not only national authorities, but also educational institutions, researchers and healthcare workers throughout the world have access to the information.
Since the turn of the millennium, the World Health Organization’s traditional leadership role in international health has been challenged by several new players, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi –The Vaccine Alliance, and Unitaid (5). These new organisations have been formed not only as a result of growing interest in and better financing of global health issues, but also because many have found the World Health Organization to be insufficiently effective. Norway has contributed to several of the new initiatives (6). Coordination between the various actors could be even better, especially in terms of improvement of the public health system and universal health coverage in developing countries (7).
Globalisation entails an increased risk of the spread of both known and new communicable diseases. Antimicrobial resistance is spreading globally and may threaten the ability to treat common infectious illnesses. International health regulations to prevent the spread of infection across national borders represent an important instrument to strengthen national competence in infection prevention and control (1). However, much remains to be achieved before all countries have the capacity to detect, investigate and report on communicable diseases and health threats.
Combatting disease outbreaks, epidemics and health crises of international importance has been an essential function for the World Health Organization, but has not been mentioned explicitly as its main remit. It has therefore been recommended that global health security must be defined more clearly as one of its core functions (8). As a result of an inadequate response to the Ebola epidemic and after several internal and independent assessments, a new programme for international health emergencies was established by the World Health Organization in 2016 (9–11). One of the most important tasks for the new Director-General will be to regain the trust of the global community in the organisation’s ability to manage global health crises and disease outbreaks.
In order for the new programme to work, the member states must have confidence that the World Health Organization will succeed in this endeavour. It is the member states that must provide sufficient funding – for example to the USD 100 million Contingency Fund for Emergencies, which is still significantly underfunded (12). There are signs that in recent years the organisation has managed to amass knowledge and experience that enable it to respond effectively to major disasters. For example, authorities and partner organisations called attention to its valuable work in connection with the earthquake in Nepal in April 2015 (13).
The organisation’s main tasks in crisis situations are coordination and leadership of health sector response, situation analysis and monitoring of disease outbreaks (14). This requires good leadership and capable staff who can cooperate effectively with national authorities, international emergency aid organisations and civil society. The World Health Organization must do more to attract the best talents, find expertise based on current needs and continue to utilise specialists from established international networks, including the Norwegian Institute of Public Health (15).
Countries with the greatest need
Universal health coverage – one of the UN’s sustainable development goals for 2030 – is one of the main tasks of the World Health Organization. The goal is equal access to health services for everyone, sustainable financing, an adequate number of health workers, affordable essential medicines and health products and a functioning health information system. In order to achieve this, the organisation must do more to ensure a presence in the countries that need it most.
Evaluation of its work shows that the organisation must become more strategic based on the needs of individual countries, and that capable management and employees are absolutely crucial (16). The possibility of collaborating closely with national health authorities is advantageous, while the organisation must also challenge the authorities when necessary. The World Health Organization has been criticised for collaborating too closely with national health authorities and for not taking an unpopular stance when needed.
In 2016, after two years of negotiations, the World Health Assembly adopted a framework for the World Health Organization’s engagement with non-state actors (FENSA) (17). The framework is intended to strengthen the engagement with NGOs, the private sector, non-profit foundations and academic institutions – while also avoiding conflicts of interest and undue influence. The World Health Organization must not allow itself to be influenced by private interests. During the swine flu epidemic in 2009, advisers were accused of being too closely tied to vaccine manufacturers (18). During the work on new guidelines for sugar intake, published in 2015, the organisation came under strong pressure from sugar industry interests (19, 20).
In order to promote equality and better access to healthcare services, particularly for countries in Africa and Asia, civil society is an important partner at the global and national level. The World Health Organization also needs support from non-state actors to promote public health measures to combat lifestyle diseases such as cardiovascular disease, cancer, obesity and type 2 diabetes.
Collaboration with academic institutions, including those given the status of WHO collaborating centres, means that the organisation can benefit from national and international academic communities. It has been criticised for being involved in too many disciplines, and for its activities being too extensive in relation to the funds available. A greater use of partners and collaborating centres will make it possible to have fewer technical experts within the organisation.
The reform of the World Health Organization began in 2011 due to economic problems following the financial crisis (21). The aim has been to prioritise better, adapt the organisational structure based on the funds available and the needs of member states, demonstrate results and undertake regular evaluation of the organisation’s work. Another important aspect has been to make changes to governing bodies to provide member states with greater influence and a more open and transparent process for electing the Director-General. Tedros Adhanom Ghebreyesu is the first leader elected under the new election process whereby the candidates are subject to public scrutiny.
The majority of the organisation’s experts are recruited regionally, for example most of the professional staff in the AFRO region come from African countries. A worldwide organisation should recruit globally in order to acquire employees with the best possible competence and experience. Rotation and mobility of staff is key to ensuring breadth of experience and professionalism, and becomes mandatory from 2018, although the employee organisations, especially in the Geneva headquarters, have not been the driving force for this process. There are currently few Norwegian staff, and Norway is on a list of countries that are under-represented (22).
Fixed contributions from member states constitute less than 30 % of the budget. The main funding comes from voluntary contributions, principally from the member states. Many of the voluntary contributions are designated as earmarked funding, resulting in insufficient resources for programmes for chronic and non-communicable diseases and food security. The USA has been an important contributor, but the current US administration has signalled that it will cut support to UN organisations. Securing more predictable funding is crucial.
There is still broad support for the World Health Organization’s central role and mandate in the field of global health. However the new Director-General is taking over an organization with many organisational challenges, that is underfunded and must demonstrate that it can unite its member states to tackle global health problems. To achieve this, it needs a strong leader with political and diplomatic flair who can make necessary decisions even when these may challenge member states and staff. Norway must actively support the work to reinforce the organisation. This is not only in Norway’s interest; it is essential for the entire global community.