Intended for healthcare professionals

Analysis

How to choose the world’s top health diplomat

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5746 (Published 28 October 2016) Cite this as: BMJ 2016;355:i5746
  1. Ilona Kickbusch, director1,
  2. Ngaire Woods, dean2,
  3. Peter Piot, director3,
  4. Kamran Abbasi, executive editor4
  1. 1Global Health Centre, Graduate Institute for International and Development Studies, Geneva, Switzerland
  2. 2Blavatnik School of Government and Director of the Global Economic Governance Programme, University of Oxford, Oxford, UK
  3. 3London School of Hygiene and Tropical Medicine, London, UK
  4. 4The BMJ, London, UK
  1. Correspondence to: Ilona.Kickbusch{at}graduateinstitute.ch
  • Accepted 24 October 2016

Ilona Kickbusch and colleagues discuss the qualities required for the next director general of the World Health Organization

In May 2017 a new director general of the World Health Organization will be elected—one of the world’s most critical appointments. The process is long and highly political. In January 2017 the executive board of WHO will shortlist a maximum of three candidates from the field of six (table 1), and the new director general will be elected from the shortlist by all 194 member states at the World Health Assembly in May 2017.

Table 1

Candidates for WHO director general1

View this table:

What does the job of director general involve?

WHO has outlined selection criteria (box 1), but the position is ultimately a political one. Technical excellence in public health is only part of the requirement, although it does provide additional credibility and insight for decision making.

Box 1: Job criteria

Under resolution WHA65.152 the candidates nominated by the board should fulfil the following criteria, while underscoring the paramount importance of professional qualifications and integrity and the need to pay due regard to equitable geographical representation, as well as gender balance:

  • A strong technical background in a health field, including experience in public health

  • Exposure to, and extensive experience in, international health

  • Demonstrable leadership skills and experience

  • Excellent communication and advocacy skills

  • Demonstrable competence in organisational management

  • Sensitivity to cultural, social, and political differences

  • Strong commitment to the mission and objectives of WHO

  • Good health conditions required of all staff members of the organisation

  • Sufficient skill in at least one of the official working languages of the Executive Board and the Health Assembly

It is a powerful role—the director general can declare a public health emergency of international concern. They are in regular contact with the UN secretary general, heads of state, political leaders, development banks, ministers of health, and major funders. Using the authority granted by the WHO constitution, the director general can choose to name and shame countries or opt for quiet diplomacy, depending on what they think is in the best interests of strengthening WHO and achieving better health for all.

What challenges does the director general face?

The director general heads an organisation of more than 7000 staff. WHO’s budget of about $2bn (£1.6bn; €1.8bn) a year has considerable impact on the global economy and on the profits of multinational companies. For example, WHO has norms and standards in relation to drugs, air pollution, and tobacco control, and recommendations for universal health coverage and salt and sugar intake.

The director general is politically accountable to 194 member states, but some might argue that they are most accountable to the world’s population of over 6 billion people, whose health and lives are at stake. If the organisation fails in one area the repercussions may affect the political and financial support it receives for its work as a whole.

Big issues loom for WHO. The most urgent of these is earning the moral and political right to lead on infectious diseases and outbreaks, such as antimicrobial resistance. Others include taking a leadership position on planetary health; stemming the tide of chronic diseases; tackling the commercial determinants of health, including drug regulation; and implementing the Sustainable Development Goals.

To tackle these challenges, the next director general must articulate a clear set of priorities for the organisation, communicate the goals and vision, and move ahead with plans in the face of frustration. Specifically, candidates for director general should clearly outline the three or four health challenges they wish to tackle and outline the governance approaches—inside and outside the organisation—required to achieve results. They must also decide what WHO should not do.

Reform of WHO is widely discussed.3 One problem is that member states and other global health stakeholders misunderstand the reality of multilateralism and underestimate the complexity of WHO’s work. The director general needs to involve these stakeholders in the reform agenda and to show how WHO can deliver globally and at the country level. Placing a high priority on accountability and transparency is also important.

WHO is currently insufficiently funded, inadequately managed, and severely criticised. The Ebola emergency reinforced the view that WHO is in crisis.4 The key immediate task for the next director general will be to restore trust and confidence in the institution. The challenges are great and so are the expectations of WHO’s new leader.

From director to general: what kind of leader is required?

Health is a tough battlefield of public and private forces and political interests. Different stakeholders seek different qualities in a director general, although all seem to agree on the need for “more leadership.”5 But the complexity of leading WHO is easily underestimated, and no director general can succeed without a strong team to support them. The new director general must appoint an interdisciplinary team of the best minds in global health.

The Blavatnik School of Government assessed the leadership characteristics needed for UN organisations. These were to broker consensus based on a vision and an interpretation of the organisation’s mandate; to secure the budget and expand core resources; to deliver results; to maintain staff morale; and to apply and enforce organisational ethics.6 These factors contributed to Antonio Guterres’s election as UN secretary general. As the Economist put it, “He knows how to communicate to the world and knock powerful heads together.”7

The Blavatnik list may seem unexciting to those hoping for a saviour of WHO with great charisma or for an “anti-establishment candidate” with a commitment to human rights, opposed to powerful companies, and critical of countries that do not fulfil their obligations. But even pragmatists recognise the importance of infusing leadership with meaning. Courage to speak out on behalf of people and patients is rated highly. A good leader needs to be authentic and a protector of the public.

But the subtle political skills needed for sustainable change should not be underestimated. These enable the evolution from a secretary general or director general to a general with significant influence. A recent tweet highlighted the hope being placed in the capabilities of the next head of WHO by calling for a “hybrid of Bernie Sanders, Barack Obama, Pope Francis, Joanne Liu, and Margaret Chan.”8

Leading WHO requires constant internal negotiations, balancing the interests of 194 member states and aligning six regional offices and 150 offices in countries, territories, and areas. The failure of a head of a country office can mean a crisis for the whole of WHO. It also involves building relationships with other health and non-health organisations, UN bodies, civil society, political clubs and regional bodies, and a wide range of new stakeholders.

Expectations of WHO are voiced by the UN General Assembly, the UN Security Council, the G7, and the G20. The WHO director general is increasingly required to engage with the public. Now that news travels so fast and by many channels, they must be an extraordinary communicator, especially in a health crisis.

The political nature of the role means that candidates must be scrutinised for UN specific leadership qualities—commitment to the values of the UN, the ability to navigate UN bureaucracy, an understanding of how states behave, the ability to identify solutions to both short and long term problems, and the ability to convince states that collective action is beneficial in a time of increasing nationalism. Making decisions under pressure, solving conflicts, creating coalitions, and convincing states to cooperate are prime skills required for running a complex UN organisation.

A director general may wish they had the power to change how global health is governed. Sometimes that opportunity does arise, invariably in a crisis, and it must be taken with courage, determination, and foresight. A successful leadership is context and time specific and dependent on luck. When one British prime minister was asked what he most feared in his term of office, he replied, “Events, dear boy, events.”9

Lessons from history: political requirements of leading WHO

Health has moved into the political realm in ways we didn’t imagine 10 years ago, and the major skills required of a director general and their team will be political. This leadership style was embodied by Gro Harlem Brundtland, former prime minister of Norway, who became director general in 1998 (table 2). As an experienced politician and national leader, she helped WHO make a political impact. During her single term in office WHO changed the paradigm from international to global health and brokered two major international agreements: the revised International Health Regulation and the Framework Convention on Tobacco Control. Brundtland is often cited as the type of heroic leader WHO needs now,10 yet even she was unable to change the internal working of the organisation in a sustainable manner.

Table 2

Director generals of WHO

View this table:

By contrast, Margaret Chan, the current director general, is often criticised for her consensual leadership style—she defers frequently to member states. Halfdan Mahler, another former director general, was a great orator, which chimes with calls for a director general who speaks truth to power.11

A fundamental problem for WHO, and any intergovernmental organisation, is that the interests of member states are often mutually exclusive, and the states may need to be cajoled into collective action. A director general and their team must be familiar with every diplomatic strategy and skill and must apply them for the benefit of world health. They must balance directing and convening with cajoling and challenging. Based on the successful leadership of other intergovernmental organisations, the first step is to establish trust. Countries then tend to give leaders ample freedom to operate, and new avenues for action open up. The constitution of WHO provides more flexibility to the director general than most people realise.

Opening up the debate and selection process

Rather than a completely closed election, the selection process for the next director general will be a more open dialogue with candidates, similar to the public scrutiny of candidates for the secretary general of the UN.12

Candidates will be questioned by member states at the beginning of November in a webcast organised by WHO, the first such event in a director general election. Other opportunities to cross examine the candidates are being organised by stakeholders, think tanks, and academic institutions.

Candidates are required to present their visions and priorities as if this was a presidential race. Most of them now have glossy campaign materials and Twitter accounts and are promoting themselves and their agendas, supported by the diplomatic apparatus of their countries.

Despite this flurry of public activity, choosing the world’s most important health diplomat remains a secretive process. The votes at the executive board and the World Health Assembly are still conducted by secret ballot. And just as with the UN secretary general, the decision is driven more by foreign policy considerations than by health goals—foreign ministries not health ministries will decide who to support. Winning the vote of a country depends on the quality of its foreign service, using political alliances and striking deals. Conflicts may exist between the health and foreign ministries, and votes may be bought.13 Non-governmental organisations can aid transparency by asking their government which candidate they intend to vote for and why.

Despite new rules for the candidates, governing the behaviour of member states remains the same. Even though a code of conduct exists, anything goes in terms of running campaigns. Power and money still talk. Promising positions in the new leadership team or financing programmes in countries are used to gain support. Striking deals on the leadership of UN organisations is another vote winner, especially as several senior positions will be available in 2017.

Opportunities for the new director general

Member states are in the process of deciding on the budget and the priorities of WHO and will agree the programme budget for 2018-19 at the World Health Assembly in May. The new director general will need to establish a new deal with those who pay for most of WHO’s work, which is a small group of countries plus the Bill and Melinda Gates Foundation. Sufficient and reliable funding is critical. In her last months in office, Chan has set herself a goal to convince countries to increase their assessed contributions to WHO.

Concern about the election is understandable.13 14 There is no clear front runner, which shifts focus to campaign efforts. A fundamental commitment to excellence, which includes gender balance, must be clearly communicated to member states, instead of promising positions for votes. The challenge to regain trust also extends towards staff, in order to keep the best and attract the best.

The new director general must be both tough and emphatic with member states but should also have the ability to work effectively with civil society organisations, the media, and the general public. A leader must be seen to act on the ground, in parliaments, and on social media. These skills will be required to implement the new Framework of Engagement with Non-State Actors and make sure it serves the organisation’s goals rather than weighs it down.15

Member states must not only select a new director general but also recommit to WHO. They need to provide the global support required primarily to prevent, but also to respond rapidly to, health crises. Countries must grant WHO technical independence and avoid micromanagement, leaving the new director general to make tough decisions that will put the organisation on track. Member states must let the director general of WHO direct in times of peace and behave like a general in moments of crisis. It is time to push the re-set button.

Footnotes

  • Contributors and sources: This article was written following a high level multi-stakeholder roundtable organised by the Global Health Centre (GHC) of the Graduate Institute of International and Development Studies in Geneva and the Blavatnik School of Government of the University of Oxford. It was an activity of the GHC project “What defines global health leadership in the 21st century?” supported by the Rockefeller Foundation.

  • The authors are grateful to participants of the roundtable, including Tobias Bergner, Garry Conille, Amanda Glassman, Steve Landry, Joanne Liu, Precious Matsoso, Yasuhide Nakamura, Joy Phumaphi, Peter Sands, Achim Steiner, Devi Sridhar, Edward Whiting and Zheng Xie, for their active participation and valuable contribution. The text reflects the views of the authors. We acknowledge the support of Austin Liu for helping with additional research for this article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed

References

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