These questions and answers were originally published in The Lancet. They provide an excellent insight into Dr Nabarro’s thoughts and possible future plans.
Priorities - What would be your priorities as DG of WHO?
As the Director-General of WHO, I would ensure that WHO can deliver in four areas: (1) alignment with the Sustainable Development Goals; (2) transforming WHO to respond to outbreaks and health emergencies; (3) trusted engagement with Member States; and (4) advancing people-centred health policies.
The 2030 Agenda for Sustainable Development – with its focus on equity, inclusiveness and leaving no-one behind – builds on the spirit of Primary Health Care, championed by WHO’s Member States for four decades. WHO’s contribution to the SDGs should include: enabling all people everywhere to attain the highest possible standard of health; continuing attention to health’s economic, social, political and environmental determinants; completing the unfinished work for the Millennium Development Goals; addressing the growing challenge non-communicable diseases; and ensuring universal access to effective health services, medicines, technologies and financial protection. In all my work within the UN system I have encouraged horizontal, cross-disciplinary, inter-sectoral working and have advocated whole of government and whole of society approaches that will be needed to address the SDG health agenda.
Ensuring capacity to prepare for and respond to disease outbreaks and health emergencies will always be a key priority of WHO. It must do this in ways that are predictable, robust and reliable, and that reflect the interests of all nations and peoples. This will include developing national capacities in line with the International Health Regulations; encouraging strategic research and innovation; urgent strategic action on anti-microbial resistance; giving special attention to the needs of vulnerable and threatened communities – including those who seek to move and take refuge so as to escape suffering; and reinforcing effective global responses to severe health crises. I intend to complete the work needed to secure WHO’s credibility as an organization with both the normative excellence and the operational agility needed to lead responses to health crises.
When engaging with Member States, WHO should be seen as the strategic leader, innovator, catalyst and convener for people’s health. WHO should do this in ways that reflect both current realities and the needs of coming decades. This requires a culture that constantly heeds the interests and concerns of Member States and their people; that leads through empowerment and example, that engages with all other actors and thought leaders committed to promoting health and health equity, and that encourages all concerned to trust the effectiveness and responsiveness of WHO.
In advancing people-centred health policies, WHO should serve as a champion for the interests, well-being and capabilities of all health care providers. WHO should intensify efforts to ensure the effectiveness of health caregivers, encouraging skills development and competency testing, and protecting the interests (and physical safety) of all who sustain people’s health in households, communities, workplaces, health care facilities and institutions.
Community engagement and inclusive partnering will be critical for each and every one of these priorities. I have seen the importance of community ownership and engagement in all my professional work. I have seen how Ebola eventually caused families to change how they buried their dead, and appreciated the heartache caused by this profound change of practice. I see how Zika now challenges women to reconsider when they become pregnant. These decisions on how a person comes into the world, how they leave it and how they are supported when they are ill are the most intimate decisions people make and often reflect firmly-held belief systems. That is why people and their representatives (civil society, faith leaders, traditional leaders, and women’s groups) need to be engaged, and listened to, whenever health policies are being shaped and implemented.
Inclusive partnering means engaging in broad coalitions and nurturing movements for transformative change. It will require transparent handling of multiple interests and encourage guaranteed and inclusive involvement of less powerful but vitally important stakeholders – be they small nations, minority groups, people with special needs or those who are so often neither seen nor heard, and are often left behind.
Limitations - WHO cannot do everything. What should WHO not do?
Policy decisions as to what WHO should (or should not) do will be made by Member States. In principle WHO has to be prepared to help countries address any threat to their people’s health. Situations will arise when WHO takes the lead on specific issues. But usually WHO provides technical support to national authorities as they address specific health issues: in these situations WHO may also serve as a catalyst, facilitator or convener. This calls for strategic leadership that is both confident and effective – to define priorities, support those responsible for implementation and establish the roles of different actors.
Global stewardship is important. It means drawing on the strengths of All of WHO. As Director General I will encourage each of the levels of WHO to contribute according to their respective strengths, ensuring clear delineation of responsibilities and accountability for the use of resources. I will do this at all times in conjunction with the Regional Directors and their teams.
Threats to Health - What are the three biggest threats to the health of peoples across the world?
Poverty, inequality and weak governance: People’s health is undermined if they do not have reliable access to adequate income, nutritious food, water, sanitation and shelter. These factors are further exacerbated when there is conflict, political instability, fragility, abuse of human rights, and inequitable economic growth. In combination, these factors contribute to the breakdown of basic health systems, a lack of basic needs, inadequate financial protection and – inevitably – a further spiral of ill health and poverty.
Existing and emerging infections: Outbreaks of infectious disease undermine economies, society and stability: hence the need to promote health security, and reduce risks due to HIV/AIDS, Malaria, Tuberculosis, diarrheal diseases and other existing infections. With hotter temperatures, heavier rainfall, increased urbanization and changes in livestock production, patterns of disease incidence alter. This results in increased risks of people being affected by vector-borne and zoonotic diseases with epidemic potential.
Low priority for health and health care: If health not given sufficient attention in global, national and local governance and policy making, people are more likely to face serious illness and to become poorer as a result. This can be the case when levels of investment in health are low or inequitable; when competing economic interests undermine health; when there is no cross-sectoral action for health or when there is insufficient investment in opportunities for physical activity and nutrition among young people. Such policy deficits can increase risks of illness arising from climate change and undermine efforts to address NCD risk factors. Challenges will be even greater if there is insufficient attention to the growing threat of anti-microbial resistance.
Tackling the Threats - What would you do to tackle those threats?
Three elements are critical – the 2030 Agenda, the One Health Approach, and political advocacy.
The 2030 Agenda offers a framework for establishing positive linkages between health and the other sustainable development goals. It will be important for WHO to ensure that attention is paid to health when policymakers take decisions on how they deal with migrants, how to conduct war, how they regulate the environment. WHO will need to encourage and support and all of government approach, making sure that ministries of health are working alongside ministries of sanitation, social welfare, and security.
Similarly, the One Health approach focuses on the issues that emerge at the interface between animals, humans and the ecosystems in which they live. This is evolving into the concept of planetary health that seeks to integrate human health within on-going dialogues on climate-compatible economic growth, resilient livelihoods, sustainable infrastructure, the future of land and oceans, urbanization and industrial development. Examination of the connections within different settings quickly exposes immediate or potential opportunities for health improvement through action in sectors and disciplines other than health.
Finally, WHO will always need to be an advocate for health outcomes: elevating and maintaining health as a priority on political agendas at all levels. In recent years, political groupings such as the African Union, Association of Southeast Asian Nations, the European Union, the G7 and the G20, as well as the United Nations, have increasingly focused on health as a priority. It is important that WHO is plays its part in such settings to explain, interpret and be ready to advance issues as leaders provide political impetus for health. Antimicrobial Resistance was highlighted in this way at the 71st UN General Assembly in New York in September 2016.
Sustainable Development - What does sustainable development mean to you, and how can WHO make the greatest contribution to the SDGs?
Sustainable development, as set out in the 2030 Agenda for Sustainable Development adopted by Member States, provides a universal framework to be pursued by all Governments, businesses, civil society and individuals everywhere. It is the plan for our common future – for people, planet, prosperity and peace through partnership. Implementation of this agenda – in concert with other multilateral agreements on disaster risk, financing for development, climate change, migration and antimicrobial resistance – can be expected to have a dramatic impact on people’s abilities to be healthy and to access care in case of illness. This is a result of the connectedness of the 17 goals, though is explicitly set out in Goal 3 with its emphasis on universal health coverage.
As discussed above, WHO’s contribution to the SDGs should include: enabling all people everywhere to attain the highest possible standard of health; continuing attention to health’s economic, social, political and environmental determinants; completing the unfinished work for the Millennium Development Goals; addressing the growing challenge non-communicable diseases; and ensuring universal access to effective health services, medicines, technologies and financial protection.
Trust - WHO lost credibility over its handling of the Ebola virus outbreak. What must WHO do to rebuild the trust of governments and their citizens?
The cultural, institutional and organizational changes needed in WHO have been clearly set out in the report of the Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies, a group which I chaired from 2015 – 2016. The changes suggested in this report have been internalized within WHO – and will be progressively reflected in the performance of country, regional and headquarters offices. Implementation has started: it needs to be sustained in a continuous and consistent way with the support of the Independent Oversight and Advisory Committee that will provide recommendation on options for improvement. Over time, as new levels of performance are achieved and benchmarked, credibility and confidence will return, additional funds will be mobilized and WHO’s contribution to outbreak prevention, preparedness and response, as well as in health emergencies, will reach the standard required by Member States.
Reforms - Does WHO need further reform? If so, what reforms would you implement?
Looking ahead, I see WHO as a magnet that attracts talented people, builds their skills over time and deploys them in ways in which they can be most effective. This is increasingly being achieved through skillful, empowered and accountable managers at all levels of the organization. I see WHO as an organization that increasingly manages scarce funds creatively, transparently and with clear lines of accountability. I would also like to see these features of the organization better advanced, appreciated and understood – within and outside WHO.
All multilateral organizations need constant transformation to ensure that their systems, priorities and processes are responsive to the changing political, technological, environmental, social, cultural and economic contexts of people’s lives. I expect WHO to remain an active player in the transformation of the wider UN system in line with the 2030 Agenda for Sustainable Development, seeking ways to ensure the relevance of individual agencies as well as coherence of international systems as a whole.
There will be times when substantive transformation is needed to tune up a particular aspect of an organization’s performance. This occurred during the 2014 – 15 Ebola outbreak. WHO has been affected by the criticisms it received in relation to handling complex disease outbreaks. The flexibility and willingness of professionals inside and outside WHO – adjusting effectively to new ways of working – has shown that WHO can function as an organic and adaptable entity.
Member States will continue to debate ways in which the governance undertaken by the Executive Board and the World Health Assembly enables the Secretariat to be more effective and contributes to the global influence of the WHO as a whole. There will remain the constant challenge of aligning finance to desired outcomes. This will include ensuring that any tradeoffs in ways resources are allocated reflect the interests of people who are at risk of ill health and for whom illness has the greatest consequences.
The Director General is expected to steer the process of transformation, to affirm priorities and to encourage partnering when this can be helpful. When Director General I will encourage WHO personnel to develop the collective capabilities and confidence they need to see their Organization as a technical leader that contributes to better lives for everyone. WHO is now moving in the right direction: the challenge is to help all who are within or associated with it to recognize the contributions they make. They should come to appreciate that although these contributions are never as great as they would wish, they should be confident that they are organizing and partnering in ways that have substantial impact for people in many different places. Through their inspiration and example, I expect that WHO senior managers will continue to lead the process of transformation, and be partners with the Director General in achieving even more.
Threats to WHO - What are the biggest threats facing WHO in the next 5 years? How will you address these threats?
It is likely that WHO will experience four major threats to its effectiveness:
Finance: With significant fixed costs, the effects of inflation and a static budget, it is difficult to increase both efficiency and effectiveness without any reduction in the tasks being undertaken. Dependence on specified voluntary contributions is inevitable, though it is important to ensure that these do not encourage the Organization to pursue activities that might be better carried out by others or that divert resources from higher priority activities that are less well-funded. The financing reforms initiated by the current administration, which focus on alignment, transparency and impact, are moving in the right direction and should be sustained.
Locating and employing strategic leaders: WHO continues to depend on its human resources – maintaining a diverse pools of highly skilled and experienced experts who have the skills needed to work effectively with Member States. Volatile voluntary funding inevitably leads to widespread use of short-term hiring arrangements: this makes it difficult for managers to maintain these pools. Innovative means for accessing experts from national institutions (with appropriate geographical balance and diversity) should be sustained, with care to ensure they function within the WHO culture, norms and operating procedures. Being a WHO staff member needs to be synonymous with both technical excellence and the ability to work effectively with national authorities.
Maintaining space for interaction, handling multiple interests and sustaining integrity: Multiple stakeholders are involved in global health. They include civil society networks, individual NGOs at international, national and community level, professional associations, the media, think tanks, national and transnational corporations. They also now include articulate individuals and informal communities of advocates with strong voices and novel influence thanks to information technology, social media and organizational skills. While this is a welcome development, this multiplicity of actors engage with WHO because they seek to influence decision making. This can be challenging both for WHO’s Member States and for the Secretariat.
Governance: It is important to ensure the primacy of WHO’s governors, the Member States, when policy decisions are made. It is also important to ensure that the expertise and independence of the Secretariat are protected when standard setting work is undertaken. And, given the increasing significance of multi-stakeholder working, it is important that safe spaces exist for all parties to interact. These spaces should enable the inclusion of those who might lack the power they need to ensure their voices are heard and presence is felt. I have substantial experience in partnering and fostering movements and appreciate the careful balance that is required to benefit from the work of multiple stakeholders, while maintaining the independence of the technical and normative functions that need to be undertaken from within the UN system.
Novel threats: The global health community has learnt to anticipate unexpected threats – whatever the cause. The transformation of WHO’s work in outbreaks and emergencies will lead to a more predictable, agile, and effective capacity for action. This will always involve WHO working with other entities in ways that reflect comparative advantages. When an incident occurs and a response is triggered, pre-planned procedures should engage a broad range of operational entities, strategic partners and international political actors at the highest level. It is now well-recognized that simulations involving critical experts from within government, UN, NGOs, scientists, business and media are invaluable. Results must be shared with world leaders at regular intervals so that they can appreciate states of readiness and institute necessary system changes to ensure that they are able to contain extreme threats to people’s health and global stability.
Role of WHO - Should WHO be a leader in health or should it only respond to the wishes of member-states?
As strategic leader for world health, WHO needs to appreciate and be responsive to the needs of Member States and their people. This means that WHO needs to support national governments in the pursuit of health objectives, providing excellent technical advice, identifying gaps in national capacities and engaging in political advocacy to ensure such gaps are addressed. At the same time, just as world leaders pledged to leave no one behind when they adopted the 2030 Agenda for Sustainable Development, WHO must strive to listen and respond to all stakeholders, ensuring that the most vulnerable and those that are hardest to reach have access to quality health services.
In this context leadership is vital: it must be both strategic and sensitive. WHO’s health leaders need to use diplomatic skills to broker constructive agreement and avoid gridlock when national interests diverge. They need to make it clear at the highest levels of government when States fail to honour international regulations in ways that impact on the health of their own or other populations. They need to use the power of evidence to hold up a mirror to States’ performance. They should be ready to champion issues that are vital to the right to health while recognizing that for some Members these may be controversial. They must be able to accept criticism and acknowledge that their judgements will be questioned.
Skills - What unique skills would you bring to the job of WHO Director-General?
I have extensive experience from work within communities in South East Asia, East Africa, the Middle East and Latin America. I have led a range of health and development initiatives, always analyzing them from the perspective of their impact on the well-being of people, their households and their territories. I know the major organizations and players in global health, and have worked with many of them since their foundation. I have worked in senior positions within WHO and have experience of transforming work on outbreaks and emergencies. I offer a safe pair of hands in crises and am effective at bringing different actors together so they work in synergy. I have developed the ability to work with world leaders in fostering partnerships and collaborative environments through which diverse interests and actors come together in pursuit of common goals and measure their achievements. I enjoy that aspect of my work very much indeed.
My leadership within WHO has included roles on malaria control, environmental health, health emergencies and the office of a previous Director-General. I understand the challenges of managing transformation in WHO and know that success calls for working effectively across all levels and elements of the organization in ways that enable all to contribute effectively. I have senior management experience within a major donor government and understand the world of bilateral development agencies. As an adviser to successive Secretaries-General I have become familiar with many aspects of the UN system and ways in which it can contribute to advancing personal, community, national and international health. One of my main responsibilities over the past year has been to work with the heads of all the entities in the UN system as they work together for the sustainable development goals and act on climate change. As Director-General, I will build on these relationships and seek to increase the extent to which the entire UN system focuses on people’s health.