[procaare] Lancet Perspective: The next Director-General of WHO

["Richard Horton" <procaare@healthnet.org>]

The next Director-General of WHO
By Richard Horton*
The Lancet 2006; 368:1213-1214
DOI:10.1016/S0140-6736(06)69496-8
**********************************

For the first time in this year's campaign for a new Director-General at 
WHO, The Lancet this week opens a debate between candidates about their 
vision for the world's most important health agency. We publish responses 
from nominees to questions about the role of WHO, their first 100 days in 
office, what WHO should not do, the agency's independence, the health of 
citizens as opposed to the needs of governments, and the increasing 
politicisation of global health. These questions help to draw out some stark 
differences between those seeking office. On the basis of their answers, 
together with the platforms they have so far set out, I try to answer the 
question WHO's Executive Board will have to address on Nov 6-8: who should 
be their next Director-General?

The 13 candidates offer very different manifestos. The confidence of their 
responses to questions-and the detail they provide-largely reflects their 
experience of global health issues and of WHO itself. For example, Alfredo 
Palacio (Ecuador) will spend his first 100 days listening and learning. 
Julio Frenk (Mexico), by contrast, will move quickly on initiatives to 
strengthen health systems, upgrade health security, and advance internal WHO 
reform.

Candidates have worked hard to carve out signature issues for their 
platforms. Kazem Behbehani (Kuwait) stresses the importance of health 
promotion. Margaret Chan (China) argues that primary health care still 
remains "the surest way to achieve sustainable health development-for all". 
Frenk puts health systems at the centre of his campaign. Nay Htun (Burma) 
will leverage the Executive Board to influence national and international 
decision making. Bernard Kouchner (France) will create a Commission on 
Ethics and Human Rights in International Health, reporting annually. Shigeru 
Omi (Japan) will continue the programme of work begun by J-W Lee. Pekka 
Puska (Finland) will try to strengthen WHO's presence at country level. And 
Tomris Türmen will launch a new youth-friendly public-health initiative.

There are some surprises. Behbehani takes an almost exclusively 
individualistic approach to health. Chan says that she is not afraid to 
prioritise. A "full-menu" strategy for health is impossible she says 
(although she refuses to give specific pledges as to which programmes she 
would back over others). Karam Karam (Lebanon) sees WHO as a damaged 
organisation in need of restored "faith, confidence, and vitality". Kouchner 
calls WHO "weak and timid". Pascoal Mocumbi (Mozambique) sees no conflict 
between the Director-General's responsibility to governments and their 
peoples, presumably ignoring the litany of human rights abuses that many 
governments perpetrate. Omi and Palacio plan to substantially decentralise 
programmes from WHO's headquarters in Geneva to Regional Directors and 
countries. Anyone familiar with the work of WHO will be alarmed at such 
commitments. Regional Office reform must take place before further resources 
are devolved from Geneva. Programmes run out of headquarters are already 
being jeopardised by J-W Lee's early efforts to decentralise. And Elena 
Salgado (Spain) claims that the evaluation of national health systems is the 
responsibility of governments, not WHO, dismissing one of the agency's major 
future priorities.

Yet the current approach to this Director-General election is the inverse of 
the way it should proceed. Before evaluating competing visions, the 
Executive Board must be sure that their preferred candidates have the right 
qualities for the job. These qualities fall into two broad 
categories-technical and administrative. The table [see 
http://images.journals.elsevierhealth.com/images/journalimages/0140-6736/PIIS0140673606694968.si1.lrg.gif ] 
rates all 13 candidates according to three measures of technical competence, 
which should all be fulfilled if the Director-General is to meet the 
expectations of member states. First, does the candidate have substantial 
(5-10 years) experience of global health practice and/or research? Second, 
does the candidate have proven scientific capacity and competence, 
especially in translating evidence into policy? And third, does the 
candidate have direct experience of managing a health system in a low-income 
or middle-income country? By these measures, the field quickly narrows to a 
small group of perhaps no more than five individuals-Frenk, Karam, Mocumbi, 
Omi, and Puska.

Administrative skills also fall into three major groupings-high-level 
political experience; proven ability to run a complex organisation and to 
deliver results; and strong communication and advocacy skills. Again, five 
candidates emerge: Chan, Frenk, David Gunnarsson (Iceland), Kouchner, and 
Palacio. The division of experience among the 13 candidates now becomes 
clear. The field has some superb technical experts and a similar number of 
excellent administrators. WHO needs a Director-General with both sets of 
skills. Only one person so far emerges with these dual credentials.

It is at this point that vision begins to play a part. The candidates that 
have articulated the strongest and most compelling agendas are few: 
Behbehani (health promotion), Chan (primary health care), Frenk (health 
systems and health security), Kouchner (universal health coverage and human 
rights), Omi (surveillance), Palacio (decentralisation), Puska (country 
focus), and Turmen (youth). Previously, I have laid out aspects of a new 
agenda for WHO based on the belief that the agency has grown in strength and 
influence under the successive leaderships of Gro Harlem Brundtland and J-W 
Lee.[1] To capitalise on this progress, WHO must go beyond the Millennium 
Development Goals, incorporating chronic disease, sexual and reproductive 
health, equity, human rights, and sustainability into its work. WHO must 
improve its country influence, acting as a stronger accountability 
instrument to measure country progress. WHO must develop more muscular 
partnerships. It must create a coherent scientific vision for its work. And 
finally, WHO must review its internal reforms, focusing much more on the 
performance management of its people and programmes. Only Frenk, Kouchner, 
and Puska come close to meeting these challenges.

The Executive Board of WHO has resolved (EB 97. R10) that the 
Director-General should have "a strong technical and public health 
background and extensive experience in international health", "competency in 
organisational management", and "proven historical evidence for public 
health leadership". By these criteria, and by the technical, administrative, 
and programmatic measures set out above, the selection of WHO's next 
Director-General is not as difficult as it might at first have seemed. Julio 
Frenk must surely be the objective front-runner for Director-General of WHO.

The reputation of the UN as a whole depends on election procedures at its 
constituent agencies that are transparent and accountable. The current WHO 
election process falls badly short of that standard. Ballots are secret, 
allowing various possibilities for corruption and horse trading. Nominating 
member states often try to buy votes. Some countries on the Executive Board 
offer their support to the candidate country that returns the biggest 
favour-eg, in foreign direct investment or future support for another UN 
position (such as Security Council membership).

The election for WHO's Director-General in 2006 is a wonderful opportunity 
for the present Executive Board to put these past failures behind them. By 
choosing the best candidate according to ability and vision, they will only 
affirm WHO's reputation and enhance its mandate.

References
[1] Horton R. WHO: strengthening the road to renewal. Lancet 2006; 367: 
1793-1795.

Affiliations
* The Lancet, London NW1 7BY, UK

Cross-posted from
"BTS eForum" <break-the-silence@eforums.healthdev.org>
October 09, 2006 8:30 PM