A Change of Guard at the WHO

Laurie Garrett | May 25, 2017 | Council on Foreign Relations

With the United States likely to pull back on global health funding, the World Health Organization, under its new director-general, will need to undertake serious structural and administrative changes.

GENEVA—For the first time in its seventy-year history, the World Health Organization (WHO) will, effective July 1, be led by a nonphysician, an African, and a person from the global South. Tedros Adhanom Ghebreyesus of Ethiopia campaigned in an unprecedented election that gave 186 nations equal voice and saw three globetrotting candidates plead their cases. In the past, the director-general of the WHO was selected in a secretive and elite process by the thirty-four members of its executive committee. This year, the entire World Health Assembly voted in three rounds of written, secret ballots; Tedros, as he prefers to be called, emerged victorious on May 23 carrying two-thirds of the votes.

Tedros has a PhD in community health and has served as his nation’s minister of health and of foreign affairs, as well as a central committee member of the ruling Ethiopian People’s Revolutionary Democratic Front party.

Despite Ethiopia’s dismal human rights record, when campaigning for the position started in 2016, U.S. President Barack Obama’s administration backed Tedros, admiring his track record as minister of health. He is credited with leading a dramatic re-envisioning of health, in which forty thousand community health workers were trained to provide basic services at the village level and hundreds of clinics were built across the large, diverse nation. These steps resulted in sharp reductions in the rates of infectious diseases like malaria and HIV, and a decrease in the number of women dying during childbirth. The United States also appreciated Tedros’s transformative role as chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria, bringing reform to an institution that had been fraught with fraud and “missing money.”

But relations between the United States and Ethiopia are complicated. The Obama administration saw Ethiopia as a bulwark against the Islamic State, al-Shabab, and other terrorist groups in the region. However, Ethiopia’s human rights record—particularly regarding the people of its Ogaden region, ethnic minorities, and journalists—has long been terrible. Most recently, the country attempted to outlaw the activities of U.S. and other foreign NGOs offering legal and humanitarian services there.

U.S. Emphasis on Health Security

For the administration of U.S. President Donald J. Trump, which initially backed Britain’s Dr. David Nabarro for the WHO job, the World Health Assembly marked its first highly public foray into global health. Health and Human Services Secretary Tom Price, a third-generation physician, journeyed to Liberia before coming to the WHO gathering in Geneva, touring facilities used during the 2014 Ebola epidemic.

In his public remarks on several occasions, both in Liberia and to the World Health Assembly, Price emphasized security concerns over outbreaks, epidemics, and bioterrorism. The WHO needs “to pursue a focused response to global health emergencies. That must be its number one priority,” he told the Assembly. “We expect the next director-general to prioritize such threats, including pandemic influenza.” In another speech at the Geneva gathering, Price stressed: “Global health security is an absolute priority for the United States.”

Tedros, in contrast, has repeatedly said, “All roads lead to universal health coverage,” or UHC, which he named his top priority for the world. Building WHO’s capacity to respond to outbreaks, epidemics, and pandemics ranks second on the director-general-elect’s priority list. In particular, Tedros will need to meet the African continent’s very high expectations of his office. As African Union Commission Chair Moussa Faki Mahamat put it in an Africa Day celebration in Geneva on the eve of the WHO vote, “This is Africa’s moment. The future is African.”

Tedros may be in for an awfully rude awakening as he works with his transition team to create a new set of WHO managers and new systems of operation. At the top of his list of challenges is money.

Funding Clouds on Horizon

During the assembly, U.S. President Trump’s proposed 2018 federal budget was released, indicating his intention to massively reduce spending on global health programs, the Centers for Disease Control and Prevention, international development more broadly, and the United Nations. The U.S. government has long been the primary donor to WHO and its allied international health organizations; in 2016, it provided $305 million, while the Bill & Melinda Gates Foundation gave $182 million. Multiple sources report that, this year, the Gates Foundation has surpassed the U.S. government as the WHO’s largest source of financial support. However, top officials from the foundation were emphatic when asked: Gates will not compensate for the reductions that the U.S. Congress may make to the WHO or other global health programs. Fearing dependency on the foundation will get out of control, its officers at the Geneva gathering told me that Gates is capping its spending.

Meanwhile, delegates at the World Health Assembly approved a two-year (2018–2019) WHO budget of $4.4 billion [PDF], including $805 million toward infectious diseases, $351 million toward noncommunicable ailments, $589 million toward building up local health systems, and $554 million toward health emergencies and outbreaks. (The budget for 2016–2017 was $4.3 billion.) However, the assembly-approved budgets are aspirations, meaning the director-general seeks to raise that money before spending. Roughly eighty percent of the WHO’s budget is voluntary, coming from large donors like the U.S. government and the Gates Foundation. For the last several years, the WHO has operated in the red and laid off large numbers of employees.

Soon, the WHO’s budgetary situation will get much worse because of, ironically, a major success story. The world is on the edge of eradicating polio, with the virus found today only in Afghanistan, Nigeria, and Pakistan. Just five cases have been identified so far this year: two in Pakistan and three in Afghanistan. In 1988, the World Health Assembly set the goal of polio eradication, at a time when about 350,000 children were paralyzed by infection annually. The WHO reckons that, since 1988, more than sixteen million people have been spared paralysis and 1.5 million lives have been saved by the Global Polio Eradication Initiative. There is great hope that polio will be vanquished within the next two years, making it only the second human disease, after smallpox, to be eradicated. That, of course, is fantastic news.

But there is a catch going forward: money. The global polio campaign has become the goose that lays golden eggs for the WHO and health programs in countries all over the world. With funds raised by Rotary Clubs International, the Gates Foundation, as well as a long list of donor nations, churches, and charities, a vast infrastructure including 250,000 volunteers and thousands of paid workers has been deployed throughout the world. When polio is declared eradicated, much of that money—especially funds generated within poor countries—is likely to evaporate. And only now, as the eradication looms, is the tremendous amount of dependency apparent.

The Polio Paradox

According to documents released by the WHO [PDF], the agency has long been using polio money for everything from salaries throughout its own infrastructure to literally funding the entire health budgets of some desperate countries, such as the Democratic Republic of Congo (DRC). Salaries for about one out of every seven of the WHO’s seven-thousand-strong workforce come from polio funds. A whopping 74 percent of all salaried WHO employees in its Africa region are salaried thru polio funds, regardless of what they actually work on. According to a WHO document released to Assembly states, the WHO has used polio funds to pay for half of all government health staff in Angola, Chad, the DRC, Nigeria, Pakistan, and even countries that have been certified free of polio for more than a decade. Moreover, polio eradication infrastructure has been used this year to stop outbreaks of yellow fever, cholera, and meningitis, to supply lifesaving Vitamin A to kids all over the world, and even to combat cancer and heart disease in poor countries. The polio infrastructure has, since 1988, become the bedrock of the WHO. If it disappears, the future of the organization is quite uncertain.

Tedros will proudly take over the reins of the WHO in July 2017, but within two years, unless he proves to be a maestro of fundraising, he will witness a house of cards fall. 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. The effort most closely allied with polio eradication, the Expanded Program of Immunization (EPI), is already appearing to weaken as countries, confident that polio will soon disappear, are becoming lax in their support for vaccine programs more generally. In Africa, more than 90 percent of EPI funding comes from the polio program; take polio away and, in theory, children across the region could stop getting every type of immunization. The main vaccination organization, the Global Alliance of Vaccinators and Immunizers (GAVI), warned the Assembly that a ripple effect is already being felt across the full range of child immunization and health programs as rates of vaccination decline.

Making the Case for WHO

I asked Tedros how he plans to keep the lights on at the WHO and at the thousands of health facilities around the world that are dependent upon the organization’s support. Acknowledging that confidence in WHO has suffered due to the agency’s slow, muddled response to the 2014 Ebola crisis, Tedros said he realizes that he must swiftly take steps to demonstrate that the WHO is a reliable and honest organization, with clear lines of financial accountability and the capacity to respond to global health needs. Secondly, he added, “whatever money we have, we have to focus it on priorities,” transferring funds from one program to another. Finally, he plans to build a professional fundraising office, akin to the one that has for decades made UNICEF successful.

“We have to make our case,” Tedros concluded. “We have to use champions to help countries and donors understand the benefits of WHO. We have to prepare, just like a court case.”

If the U.S. government retreats from funding global health, as the president’s proposed budget indicates, and the Gates Foundation cannot step in to plug the breach, pressure will mount on the G20, the private sector, and many of the world’s top charities. Without their support, the WHO, under its first African leader, could face an existential threat.