The Lancet, Editorial – The current race to replace Margaret Chan, outgoing Director-General of WHO, has been a different kind of contest. The unprecedented level of transparency and accountability in the election campaign is to be welcomed—voting by member states and not only by the agency’s executive board, publication and scrutiny of candidate manifestos, and public debates. But will the final decision making, to take place next week at the World Health Assembly in Geneva, also be different? The vote remains a secret ballot, member states can pledge their support to one candidate but vote for another, and, in the end, the choice of WHO’s next leader, still the world’s top international health post, will be as political as ever.
The election comes at a time of unparalleled uncertainty for WHO. Meeting the expectations of the Sustainable Development Goals demands political legitimacy and courageous leadership. Yet the landscape of global health initiatives has never been more complex, narrowing opportunities for WHO to play a decisive part in shaping the future of health. And WHO’s finances are terrifyingly limited. The agency is in an unenviable position: vastly more is expected of WHO while its role is contested and constrained.
A tall order for the remaining candidates, Tedros Adhanom Ghebreyesus, David Nabarro, and Sania Nishtar, who have each proved to be strong, credible, and hard working. All have participated in countless discussions and interviews, and travelled around the world competing for country votes, showcasing their particular strengths and priorities. At this juncture in the history of WHO it feels right that there are two candidates from low and middle income countries, and one a woman.
Tedros has been credited with transforming the Ethiopian health system and his country’s population health. He also has deep and valuable experience of several key global health initiatives that sometimes compete with WHO. As potentially the first Director-General from sub-Saharan Africa, his ascent to WHO’s leadership would be a major win for the continent. That said, Tedros has had to contend with considerable political mudslinging. He was Health Minister and Foreign Minister until November, 2016, leading to concerns being raised over his links with an Ethiopian regime guilty of extensive violations of human rights. Some of this criticism has been openly discussed, and also refuted, in social media. Furthermore, Tedros strenuously denies the damaging accusations (made by an adviser to his closest competitor, David Nabarro) that he covered up cholera epidemics in Ethiopia while Health Minister, branding it a smear campaign.
David Nabarro has wide experience on the front lines of global health and in the UN system, where he has spent much of his career. He has strong and proven managerial skills. And he has led and coordinated important global programmes, ranging from nutrition to Ebola. But Nabarro is supported by a present and likely future UK Government sceptical of multilateralism, distracted by Brexit, and lacking the enthusiasm of past administrations for health as an important foreign policy issue. Added to which, some member states may question whether now is the right time to be appointing a UN insider. Does WHO need fresh and more radical thinking, they might ask.
Sania Nishtar has her origins firmly rooted in civil society. A highly successful campaigner to address the abject international neglect of non-communicable diseases, she has also gained experience, albeit briefly, as Pakistan’s Health Minister, among other portfolios. She has successfully chaired important global health working groups, and she has shown an impressive independence of thinking—suggesting, for example, that she might only serve one term as Director-General to free her to take the tough decisions she believes WHO needs to take. But some observers may ask whether her high-level organisational experience is sufficient to lead WHO at such a critical moment in its history.
Each candidate has strengths. And each has weaknesses. The Lancet has, at various times, worked closely with all three. We can attest to their commitment to WHO and its values. But that is not enough. To achieve genuine internal reforms and to restore public confidence might seem to favour Tedros and Nishtar. The complex management and diplomacy requirements could favour Nabarro. The new campaign process has succeeded in enhancing transparency about the qualities and attributes of the candidates. But, as in any election, unpredictability reigns. We encourage member states to vote for the candidate who they believe mixes proven managerial competence with a clear and deliverable vision for WHO’s next 5 years. No empty promises. Just realisable results. And, perhaps most importantly, someone with the skills to handle the unexpected.