Reposted from The Lancet
Published: 07 January 2017
IMAXI Note: The process to select the next Director General of the WHO is moving forward, and will be decided by the WHO Member States in May. Although we have no say in the decision, it’s essential to learn more about the positions of the candidates. Where there are gaps, we must point them out. In the same way that we need to mobilize to support those candidates with the most progressive agendas.
A Lancet Special Report (Oct 29, p 2072)1 provided the six candidates competing for the post of the next Director-General of WHO an opportunity to briefly present their manifestos. The candidates‘ priorities are important because they will influence the agenda of WHO, the institution mandated as the directing and coordinating authority on international health.
The extent to which the candidates’ manifestos aligned with the political priorities expressed in the UN Agenda 2030 for Sustainable Development (Agenda 2030) health-related targets2 was analysed (appendix). Alignment with these ambitious yet appropriate targets3 is crucial because WHO is expected to provide the international community leadership and technical support in their realisation. The following three further principles of Agenda 2030 will be equally important for realising the health-related targets: leaving no one behind, rights-based approaches, and gender-sensitivity (a determinant of ill-health, health-seeking behaviour, and health outcomes).4 Moreover, Agenda 2030 requires different methods of working for WHO, including intersectoral collaboration, engagement with non-state actors (particularly civil society and the private sector), and addressing the social determinants of health, all of which are included in this analysis.1
Candidates prioritise certain targets and issues over others. David Nabarro mentions the highest number of targets and issues in his manifesto (19), whereas Miklós Szócska mentions the least (11). Surprisingly, many of the targets do not feature among the priorities of any candidate. Substance misuse, road traffic injuries, and neglected tropical diseases are not featured, and sexual and reproductive health are not covered, with the exception of Nabarro if “completing the unfinished work for the Millennium Development Goals” is accepted as a proxy.
This analysis raises five issues that are relevant to compare the candidates and to move their agendas forward.
First, moving from what actions to take to how to implement them is generally absent from the candidates’ agendas. For example, despite strong prioritisation of non-communicable diseases (NCDs), only one candidate mentions evidence-informed interventions identified by WHO and the World Economic Forum as “best-buys for NCDs”5—Szócska calls for an “efficient public health regulatory agenda”. Similarly, although all candidates propose commitment to universal health coverage, only three candidates mention resource mobilisation or the health-care workforce. All candidates mention access to medicines; however, none mentions trade-related aspects of intellectual property rights flexibilities—a policy lever for affordable generic drugs.
Second, the right to health is mentioned by five candidates, but fewer mention the specific needs of susceptible or marginalised groups. All candidates mention equality, but only Sania Nishtar mentions gender equality, whereas Flavia Bustreo refers to her experience mainstreaming gender through WHO. Special attention to the needs of, and non-discrimination against, less powerful groups will help address the major health inequalities (including access to health care) experienced by minority and marginalised6 populations around the world, and should be prioritised by all candidates.
Third, several health issues with substantial contributions to the global burden of disease are not on the agenda. It might be argued that in voicing their support for Agenda 2030 or universal health coverage, the candidates implicitly endorsed all the health-related targets. This justification raises questions regarding how candidates prioritised and selected the agendas presented while ignoring other equally important health issues.7
Fourth, leadership on divisive issues is absent. Rather than clear leadership informed by evidence of the burden of disease, the candidates avoided the ideological divide on sexual and reproductive health and rights. Similarly, although all candidates propose to engage more with the commercial sector, no candidates offer solutions to address the commercial drivers of ill health (diet, alcohol, road traffic accidents; only two mention tobacco) and only one refers to the WHO Framework of Engagement with Non-State Actors and how to safeguard WHO against risks from interaction with the private sector.
Finally, the candidates did not give adequate consideration to the root causes of susceptibility and risk of illness. For example, all candidates mention the need for intersectoral collaboration, but only four seek to address social determinants of health—despite a wealth of evidence from WHO on their importance—and only Nabarro and Nishtar are robust on the issue.8 Although four candidates refer to climate change as a determinant of ill health, they do so in relation to its effect on health and health-care systems rather than how to deal with climate change itself. Similarly, five candidates mention environmental pollution; however, none of the candidates address how to deal with its determinants.
The candidates’ manifestos are expected to evolve as the campaign progresses. Ultimately, health is a political issue (five of the candidates allude to this) and the selection process is a political one.9 The executive board of WHO will meet in January, 2017, to put forward a shortlist of three candidates. Civil society, experts, and member states must now push all six candidates to adopt more politically courageous, evidence-informed manifestos, aligned with globally agreed targets, to which the successful candidate can be held to account by member states and individuals whose health they serve.
See Table (Appendix):
1. Horton, R and Samarasekera, U. WHO’s Director-General candidates: visions and priorities. Lancet. 2016; 388: 2072–2095
2. UN General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the General Assembly on Sept 25, 2015. A/RES/70/1.
http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. ((accessed Nov 5, 2016).)
3. Buse, K and Hawkes, S. Health in the sustainable development goals: ready for a paradigm shift?. Global Health. 2015; 11: 13
4. Hawkes, S and Buse, K. Gender and global health: evidence, policy, and inconvenient truths. Lancet. 2013; 381: 1783–1787
5. WHO and World Economic Forum. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries. Sept 18, 2011.
http://www.who.int/nmh/publications/best_buys_summary.pdf. ((accessed Nov 12, 2016).)
6. Beyrer, C, Baral, S, Collins, C et al. The global response to HIV in men who have sex with men. Lancet. 2016; 388: 198–206
7. Bachrach, P and Barataz, MS. Decisions and non-decisions: an analytical framework. Am Polit Sci Rev. 1963; 57: 641–651
8. Marmot, M. Social determinants of health inequalities. Lancet. 2005; 365: 1099–1104
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