WHO’s Reality Check: The Election of a New Director-General for the World Health Organization

Three WHO DG candidates
Dr. David Nabarro, Dr. Sania Nishtar, and Dr. Tedros Adhanom Ghebreyesus

On 23 May 2017, the World Health Organization (WHO) will choose its next Director-General at the 70th Session of the World Health Assembly (WHA70), the plenary body of the organization in which all 194 Member States are represented. For the first time, the WHA70 will be making the real decision, which in the past was left to the 34-Member Executive Board meeting the January prior to the WHA. This change is due to election reforms that were called for by the Member States, mainly the developing States, who felt disadvantaged by the old system that for example, had contributed to preventing an African from ever holding the post of Director-General at WHO.

While the process will be the most transparent ever in the 70-year history of the organization, nevertheless it is still one that defies adequate public scrutiny and therefore remains wide-open to abuse that may lead to the decision being made based on politics rather than based on the candidates’ qualities. Below each of the candidates is briefly described and then the election process is examined. Finally, some brief comments are made about what to expect on 23 May when the WHA70 chooses a new Director-General for WHO.

The Candidates

Despite the lack of transparency of the process, there are three competent candidates are left vying for the WHO leadership after the Executive Board cut the field in half in January 2017 by eliminating three candidates, including two former ministers and the only internal candidate. The remaining three candidates, Ethiopian Dr. Tedros Adhanom Ghebreyesus, British subject Dr. David Nabarro, and Pakistani Dr. Sania Nishtar all have redeeming qualities that would serve them well in the post. They all have the ability to lead WHO, but each offers very different strengths and weaknesses.

          Dr. Tedros

Dr. Tedros, the name he goes by, is not a medical doctor but has extensive training in public health at British universities. His first degree is in biology, his Masters from the University of London is in Immunology of Infectious Diseases, and his Doctorate in Community Health is from the University of Nottingham.

His greatest advantage is his public service. He has served Ethiopia as Minister of Health for seven years and as Foreign Minister for the better part of four years. After he left the post of Foreign Minister, he has continued to serve his country as a presidential adviser even as he is campaigning for the WHO post. It is particularly his efforts as Minister of Health that earned him accolades from both foreign and domestic observers. He focused on health systems building, not merely temporary solutions. He is the only candidate with experience running a large organization anything like the size of WHO. It is, therefore, likely that he will get the votes of States that are concerned about putting the global health agency in untested hands.

He is also the only one who may be able to find the funding WHO needs because of his close relations with some of WHO leading donors. Despite his being the African candidate American millionaire Bill Gates, an advisor to the wealthy Norwegian government, and, a former United Kingdom secretary of the Department for International Development, have publicly supported Dr. Tedros for the post. This contrasts with UK candidate, whose government announced that it will cut its contributions to the WHO. It is also a factor that makes Dr. Tedros the front-runner going into the 23 May election.

But Dr. Tedros he doesn’t come without liabilities. His curriculum vitae for the post oddly lists Minister of Health as his first job. This seems to confirm the claims of his domestic critics that he is a political insider who may be too beholden to his government. It has also led to a campaign being launched by civil society actors, some with the apparent support of his British opponent Dr. Nabarrro, to implicate Dr. Tedros in human rights abuses in his country. The complaints range from his failure to speak out against the slaughter of almost 150 protesting Oromo’s in early 2016 to his alleged coverup of infectious disease outbreaks in Ethiopia.

Despite these criticisms, Dr. Tedros has maintained a good repertoire with many States, the only entities that vote. In fact, perhaps more than any candidate he has focused on speaking to the Member States at the most senior levels. Moreover, he is not only the sole African candidate in the race, but he apparently has solid backing from the African States and the African Union as a whole. He would be the first African to occupy the post in the 70-year history of the WHO.

Nevertheless, Dr. Tedros will have to watch his back as especially the United Kingdom have a record of playing dirty tricks in collaborating with the United States, to prevent an African candidate from being elected (see below). Indeed, just a week before the election emails from Dr. Nabarro to WHO and UN staff emerged in which it is clear that staff at both Un family organizations are involved in supporting his campaign in violation of both WHO and UN staff responsibilities pertaining to the election of the heads of intergovernmental organizations in the UN family.  Included on the list of email recipients, although the full emails were blacked out in the publicly released version of the email, is allegedly staff in the office of the current Director-General.

          Dr. Nabarro

Dr. Nabarro, the British candidate, likes to say that he has been training for this job all of his life. Indeed, he has an impressive list of degrees that date back to when Dr. Tedros was still a youth. After training in Animal Physiology and Biochemistry, he acquired a Masters’ degree in Medicine, a Medical Degree, and a Masters’ in Public Health, all from British Universities. As a physician, he is also a Fellow of the Royal College of Physicians of London and on their Faculty of Public Health Medicine. He has worked for grassroots medical organizations that intervened in countries in the Middle East, Asia, and Africa. He spent nine years at the UK aid agency and five in middle-level WHO positions before moving to the UN in New York to hold a series of prestigiously-titled posts. He was Special Envoy of the United Nations Secretary-General on Ebola where he coaxed the UK and other governments into a ‘quick in, quick out’ aid effort in West Africa. He has also been Special Representative of the United Nations Secretary-General for Food Security and Nutrition and Special Adviser to the Secretary-General on the 2030 Agenda for Sustainable Development and Climate Change.

While the titles Dr. Nabarro has held in recent years sound prestigious, most close UN observers, including the world’s organization’s Member States, know that those posts come with scant resources and have provided few tangible accomplishments. Moreover, when put on the front line in global health crises, Dr. Nabarro record is at best mixed and sometimes he appeared to literally fumble the ball rather than show a steady hand. As probably the most knowledgeable medically trained person in UN Headquarters during the outbreak of cholera in Haiti, instead of advising the UN to own up to its having exposed hundreds of thousands of Haitians to the deadly disease, which has now killed almost ten thousand people, Dr. Nabarro supported the UN’s coverup. His record as Ebola envoy during the West African crisis was somewhat better, but his ‘fast in, fast out’ manner of dealing with the crisis left the West African States as exposed to the deadly disease after it had been contained, as before the 2014-2015 crisis began. It was only with the development of a new vaccination in the past year under WHO’s guidance that another Ebola epidemic might be prevented and Dr. Nabarro had little to do with his effort.

Perhaps more detrimental to Dr. Nabarro’s chance of becoming the next Director-General is the fact that he is a national of a State that is a Permanent Member of the UN Security Council. Usually, the States that are a Permanent Member of the UN Security Council do not put candidates forward for the top post at the UN or WHO. This was pointed out by the UK’s former secretary of the Department for International Development, Mr. Andrew Mitchell, in an article he wrote in The Guardian newspaper on 27 April 2017, in which he endorsed Dr. Tedros for the WHO post. One reason for the unspoken rule against ‘Permanent Five candidates’ is to prevent the appearance of the arrogance of power. This is a trait, however, that many former WHO staff and others who have worked with Dr. Nabarro say is a feature of his character and may explain his willingness to buck the rule. Also damaging to his chances may be the recent revelations of Dr. Nabarro’s failure to respect the integrity and independence of UN and WHO staff by including current staff in his campaign activities.

          Dr. Nishtar

Dr. Sania Nishtar is the Pakistani candidate for the post. She is the only women left vying to replace a woman. As the only female candidate for what is often understood to the be second highest staff post in the UN system family, she has the support of States who in vain tried to put a woman in charge of the United Nations for the first time during the section of its Secretary-General in 2016. The ‘gender card’ is something that appears to have particularly endured Dr. Nishtar to some North American and the Nordic States. Ironically, it is usually coupled with a concern for women’s reproductive rights, something that she is unlikely to champion as Director-General given her strong ties with her own country, Pakistan, that holds a rather restricted view of such rights. Dr. Nishtar also has the support of the Organization of Islamic Cooperation (OIC), although this likely does not include the significant number of African OIC Member States that appear more committed to the African candidate.

Dr. Nishtar is a physician trained in Pakistan and the UK, and like Dr. Nabarro, she is a Fellow of Royal College of Physicians of London. She is also a Member College of Physicians and Surgeons of Pakistan. In addition to a medical degree, she also obtained a Ph.D. in medicine from the Kings College London. Her reputation as a writer on health issues has often been touted as one of her strongest characteristics during the campaign.

Dr. Nishtar is also a civil society candidate having worked most of her life with the NGO she set up with the assistance of her family’s wealth and a broad range of connections. While she worked for about a decade as a medical doctor, she appears to have channeled her family’s wealth into Heartfile, an NGO that she founded. Heartfile appears to have morphed from a health information organization to a health policy think-tank to serve her interests in competing for the WHO post. It did this with significant funding from the Clinton Global Initiative of former U.S. President William Clinton. Dr. Nishtar has spent most her career working with this NGO, although she frequently mentions the fact that she was a government interim minister for about two months.

Despite being ostensibly a civil society candidate, she has secured strong support from the government of Pakistan, which nominated her early in the process. This support makes her somewhat unique among the three candidates. While Dr. Tedros can order his State’s support because of his senior status within the Ethiopian own government, which he still serves as a Presidential Advisor, and Dr. Nabarro seems to be struggling to get his government’s full support, Dr. Nishtar seems to have genuinely enthusiastic support from her government.

Dr. Nishtar is by far the most curious candidate. Part of the reason for this is her rise from relative obscurity and part is the often-unchallenged hyperbole she used to make the ascent. Most notably the written curriculum vitae she submitted after the Pakistani government nominated her for the post of WHO Director General in early 2016, insinuates that she was Minister of Health by stating that she was responsible for health. Both the insinuation that she was Minister of Health as well as that she was responsible for health, however, appear to be untrue. She was Minister of Education and Training, Science and Technology, Information Technology and Telecommunications, all areas for which it is hard to find a capacity to lead WHO. Furthermore, according to her own written statement made at the end of her short tenure, she was neither Minister of Health nor responsible for health. It is perhaps not a good start to a campaign when a candidate to lead an intergovernmental organization attempts to mislead its Member States on her job application.

Moreover, no matter how she spins her qualifications Dr. Nishtar has never led an intergovernmental organization. She has never even worked full-time for an intergovernmental organization. She has also never raised or handled the funds for any large intergovernmental entity. Her international experience is based on her having served as a volunteer on several boards that meet infrequently, and perhaps, on her use of her own family’s significant wealth in promoting her own NGO. While NGOs relish the chance of a real outsider coming into to WHO the shake-up and re-enthuse the organization, it is hard to see States voting for to put WHO in such inexperienced hands. Nevertheless, if States want new blood in the WHO while still being able to maintain close control over the organization, Dr. Nishtar’s lack of experience may be something they value as it will enable them to manipulate the Secretariat. This is something that may endure her to them on 23 May.

* * *

Undoubtedly, all three candidates possess some redeeming qualities that could make any of them good Director-Generals, but it may not come down to qualifications. Instead, past practice in WHO has shown that the ability to manipulate the process may be of much greater value. In this respect, not all candidates have the same capacity to control the playing field and that is what may ultimately rule the day on 23 May. The reasons for this relate to the WHO procedure that will be followed in choosing the next Director-General.

The Procedure

The election of WHO’s Director-General will be made by its 194 Member States, minus any States that are too far behind in paying their assessed contributions, behind closed doors and by secret ballot. Rather than being an example of transparency and global democracy as is increasing being required in a globalized international community, the Member States of WHO opted for secrecy that again allows backroom and under-the-table deals. Through this opaque process, the Member States will elect a new Director-General either in one round of voting whereby one candidate receives a two-thirds majority, or, in successive rounds whereby one candidate either achieves a simple majority or one candidate is eliminated until one achieves a simple majority of the States present and voting.

WHO had the intention to take advantage of new technology and to use electronic voting. When tested, however, the newly installed system did not work adequately and the idea of electronic voting had to be scrapped. This is not the first time WHO seemed to be stymied in its transition to modern technology. At the Executive Board meeting in January 2017, the accreditation of some NGOs was significantly delayed because of a faulty online accreditation system. The system failed to display a button on computer screens that allowed for submitting accreditation requests after the required information had been entered. Although WHO admitted the flaw, repeated requests for an explanation and assurances of a fix that were made to the Assistant Director-General for General Management, did not even receive a reply. Apparently, WHO was so befuddled by its own technological gaffs that it didn’t even know how to respond. Such ostrich-like reactions do not bode well for the possibility that WHO might have had to react to a technology glitch in the voting procedure. Perhaps, therefore, the decision was made to keep voting as simple as possible.

As noted above, to vote States must have paid their annual assessed contributions, although in some cases this may mean that other States have paid the assessed contribution for a particular State. There is a suspicion that some West African States with close ties to the UK might have had assistance in paying their dues with the condition being imposed that they vote for a particular candidate. Guinea and Liberia, the former, which just recently paid its dues, have been suspected of such agreements by some NGOs who have been observing the process. To vote, States must also have a duly accredited representative present in the room when the voting takes place and that representative must cast his or her vote by walking to the podium in the front of the room when the name of their State is called, and deposit a paper ballot into a transparent ballot box. That the voting-receptacle be transparent as due to a request by the African States. Nevertheless, the transparent voting box will provide little means of controlling whether a States votes in accordance with the promises of its officials, its commitments to regional and international organizations, or even the instructions of the highest government officials in its own State.

When former Prime Minister, Minister of Health, and renown Mozambican pediatrician Dr. Pascoal Mocumbi competed for the post, the U.S.  and its allies colluded to ensure he was not chosen, apparently fearing a socialist leaning Director-General. This case dates back to the election of Director-General Lee in January 2003. Dr. Lee was elected after well-respected Director-General Dr. Gro Brundtland decided not to compete for a second term. The more well-known African candidate was eliminated by the U.S.  and its allies coaxing several African States into putting forward candidates with lesser credentials than Dr. Mocumbi. Nevertheless, the presence of multiple African candidates divided the continent’s votes and allowed the less-known Asian candidate from South Korean to triumph.

To address this, African States pushed for changes to how the Director-General would be chosen during Dr. Lee’s term, which was cut short by his sudden death while in office. The movement to reform the election process continued into Dr. Margreet Chan’s term. It was during this time that it was agreed to make the process more transparent and that geographical distribution would be a consideration for choosing the next Director-General. The notion of considering geographical origin is only generically reflected in the resolutions reforming the election process. Moreover, the implementation of these resolutions was strategically delayed by Dr. Chan, the second successive Asian candidate, until after she had been confirmed for her second term without a challenger. Nevertheless, to any credible observer who had stayed up until the late-hours of the to witness the debates on the reform of the WHO election process, it was clear that what was really being agreed was that the next Director-General would be from an African country as long as at least one credible African candidate was put forward.

Africans delegates to the WHA70 who remember the debacle surrounding the elimination of Dr. Mocumbi might be concerned that there seems to be little institutional memory of this gentlemen’s agreement. Moreover, both the UK candidate and another Asian candidate, have, of course, done their best to ignore this not so distant history of the election of the WHO Director-General.

What to Expect

While all three candidates have been intensifying their efforts to gain the support of each of WHO’s 194 Member States that will vote at WHA70, at this point any rationale prediction would have to favour Dr. Tedros. His African support has been steady and his support among the Group of 77 and the BRICS appears to be solidifying. Even his distractors such as the United Kingdom, the United States, and Canada appear to inadvertely acting in his favour as their ploys to promote other candidates appear to be driving States towards the African candidate. Moreover, few States appear willing to endure the ignominy of being dubbed racist if they again for the seventieth year of WHO’s existence pass-over a qualified African candidate.

Nevertheless, games are being played in the waning days of the race. The United Kingdom government has threatened to cut its funding to WHO, a hardly veiled threat to encourage States to vote for their candidate, Dr. Nabarro. A supporter of Dr. Nabarro also published allegations that Dr. Tedros was covering up serious health concerns in his own country. It was later reported that this person, despite his earlier claims to have been acting independently, was working on Dr. Nabarro’s election team. Moreover, a leaked email implicated several WHO staff, apparently including those in the Director-General’s own office, as being intimately involved in Dr. Nabarro’s election campaign in contravention of WHO and UN staff responsibilities regarding the campaign.

At the same time, Dr. Tedros has felt obliged to resort to an U.S. publicity agency to tidy-up his image and refute claims that he supported human rights abuses by a government he twice served as a minister and still serves as a senior adviser. He also enlisted a team of American-Ethiopian campaign managers, including a former campaign officials who worked on U.S.  President Barak Obama’s successful campaign to become the U.S.  President. This resort to Western tools has ruffled the support of some African States, but seems to have been accepted as a necessary step to address the efforts of the UK candidate especially with memories of what happened to Dr. Mocumbi still in the minds of some African leaders.

And even Dr. Nishtar, who hails from civil society but enjoys the strong support of her government and the marginal backing of the Organization of Islamic Cooperation, has felt it necessary to stretch the truth about her own experience. She has also solicited a lengthy list of individual supporters ranging relatively unknown figures to leaders in global health, but few governments have expressed their support for her. Rumours have also been rife that she and Dr. Nabarro have an agreement on shifting support to the other if one of them is eliminated in a first round of voting.

In the end, despite the election reforms implemented by WHO there seems to be ample space for manipulation of the voting, especially if no candidate gets the two-thirds majority of votes required to win in the first round. Rumours that the United Kingdom has been pressuring States through a wide-variety of means have especially fanned fears of election manipulation. For, sure, like many things in international diplomacy, the appearances at the WHA70 are likely to be deceptive. The closed nature of the process is but the darkest omen. WHO still appears to lack the resources, the normative framework, and perhaps the will to ensure that the election of its Director-General is based on the quality of the candidates, instead of invidious politics. Perhaps this will ensure that the organization itself and those it serves are the biggest losers on 23 May, no matter who wins.


By Curtis F.J. Doebbler, Research Professor of Law at the University of Makeni, Sierra Leone; Visiting Professor of Law at Webster University Geneva, and a keen observer of the WHO election process for more than three decades, currently with the NGO International-Lawyers.Org.