On May 23, the World Health Organization elected a new director-general (DG): Tedros Adhanom Ghebreyesus, known as Tedros. The first DG from an African nation, he is also the first nonmedical doctor to lead the organization. With a doctorate in public health, he served as Ethiopia’s health minister from 2005 to 2012 and foreign minister from 2012 to 2016.
This is a fraught moment in WHO’s history, given the organization’s budget crisis — and criticism during the 2014 Ebola crisis. Can Tedros succeed?
A switch in WHO elections
Tedros, who succeeds Margaret Chan from China as DG, made his name leading Ethiopia’s efforts to stem deaths from malaria, tuberculosis, AIDS and maternal mortality. He deployed tens of thousands of female health workers, improved lab services, launched aggressive efforts against disease outbreaks and improved medical training. He also served as chairman of the Global Fund to Fight AIDS, Tuberculosis and Malaria and chaired the Roll Back Malaria partnership board.
Unlike previous closed-door sessions by an executive committee, this election was the first time WHO members could vote by secret ballot, with each member-state getting a vote. It was also a more freewheeling process, with candidates openly campaigning through a series of debates and public appeals.
In the third and final round of voting, Tedros defeated David Nabarro, a long-serving WHO official supported by the U.K. The other finalist was Sania Nishtar of Pakistan, who had pledged to serve only a single five-year term. Tedros’s defeat of Nabarro, a seasoned U.N. candidate brought in to lead the Ebola effort, proved somewhat of an upset victory.
WHO is in a parlous state
WHO is no longer the sole leader in global health. It has had to compete for funds with organizations such as the Global Fund. New organizations such as the Bill and Melinda Gates Foundation have become increasingly important in setting the global health agenda. The delayed WHO response to the Ebola crisis severely damaged its standing and exposed some long-standing flaws in funding sources and structure.
Following steep budget cuts after the 2008 financial crisis, WHO reduced staff by 20 percent, including a two-thirds cut to the emergency response staff. This left WHO slow to respond to the 2014 Ebola crisis, which ultimately claimed more than 11,000 lives in West Africa.
WHO’s budget structure is another problem. In recent decades, the organization has relied overwhelmingly on voluntary contributions from member states and nonstate actors. Those funds tend to be earmarked for pet projects, potentially leaving core WHO functions like pandemic preparedness and response chronically underfunded.
The World Health Assembly, the decision-making forum of WHO member states, recently approved a biennial budget of almost $4.4 billion, which includes an increase of 3 percent in “assessed” dues to member states for the first time in over a decade. Of this budget, $805 million is designated for communicable diseases. It remains to be seen whether all of the $4.4 billion ultimately will materialize.
The Trump administration proposes to cut U.S. funding
Adding to WHO’s financial pinch, the Trump administration proposed a $2.2 billion cut in U.S. global health spending. The United States contributes 16 percent of WHO’s budget, and is the largest single source of global health aid overall. While Congress may not follow the White House’s proposal, WHO could be in serious financial trouble.
The polio eradication effort illustrates many of the problems WHO faces. This program, supported generously by the Gates Foundation and other donors, has cross-subsidized other health activities — including 74 percent of all WHO salaried workers in Africa and much of the immunization work in the region. Almost 25 percent of WHO’s budget goes to the polio campaign.
With the wild polio virus now confined to Pakistan, Afghanistan and Nigeria, what happens to WHO funding if the polio eradication effort is successful? As Council on Foreign Relations analyst Laurie Garrett warns: “Polio eradication funds and, consequently, the salaries of one-seventh of its employees will dry up; everything from maternal mortality and cervical cancer screening programs will collapse.”
Tom Frieden, former head of the U.S. Centers for Disease Control and Prevention, laid out the challenge starkly: “It’s never a great thing to walk into an organization that’s broke. So that’s a problem.”
There are other challenges
WHO faces a related challenge over how to define its core mission. In recent years, WHO has embarked on initiatives as diverse as tobacco control and obesity.
In the wake of the Ebola crisis and emerging disease threats such as Zika, rich donor countries want the organization to focus on global health security and pandemic preparedness. During its 70-year history, WHO has performed core functions like coordination and information sharing to address infectious diseases. These roles remain as relevant as ever.
Meanwhile, Tedros has suggested that his focus is health systems strengthening and universal health coverage (UHC) — so people get the health services they need without financial hardship. That could spell trouble in terms of a split between the priorities of donors and the main recipient countries Tedros represents.
On some level, these challenges are related. Weak health systems in West Africa helped create the conditions that allowed Ebola to emerge and spread. However, building health systems capacity all around the world is a difficult, expensive and slow undertaking. Even if WHO positions itself to strengthen health systems, it will always be responsible for sounding the global health alarm when infectious disease outbreaks emerge.
Tedros may be in the impossible position of trying to satisfy too many demands with not nearly enough money. He and WHO will once again be tested. In his first news conference after his victory, Tedros suggested that he wanted to diversify the financial base of support of WHO by tapping other organizations such as the vaccine alliance GAVI, and by emulating UNICEF, which raises funds via high-profile Halloween collection boxes and sponsorship from the international soccer club Barcelona
We’ve argued here in the Monkey Cage that WHO needs a leader who has both political and health expertise. As the first WHO director-general with government experience outside the health arena since Gro Harlem Brundtland’s tenure from 1998 to 2003, Tedros may fit the bill — but it will take funding as well as political experience to rescue WHO.
Joshua Busby is an associate professor at the LBJ School of Public Affairs at the University of Texas at Austin.
Karen Grépin is an associate professor in the Department of Health Sciences at Wilfrid Laurier University.
Jeremy Youde is a fellow and senior lecturer in the Department of International Relations in the Coral Bell School of Asia Pacific Affairs at Australian National University.