The Exchange: Solutions Seeker

Since taking charge of WHO in July 2017, Director-General Tedros Adhanom Ghebreyesus has sought to transform the organization. Tedros (as he likes to be known) has focused WHO on health equity, confronting new threats, and emergency preparedness and response. Chair of International Health at the Bloomberg School, David Peters, MD, DrPH ’93, MPH ’89, is a longtime health systems researcher and a WHO adviser. He knows well the challenges Tedros faces. In this Exchange, Peters probes Tedros on his signature initiative—universal health coverage—and WHO’s lessons learned from the 2014 Ebola outbreak. He also engages him on WHO’s organizational changes and the role of schools of public health.

David Peters: You’ve been clear about your priorities for WHO: addressing health equity, taking on new threats to human health and renewing WHO’s focus on emergency preparation and response. What have been the biggest challenges in pursuing these priorities? Any surprises?

Tedros Adhanom Ghebreyesus: There are several major organizational shifts I believe WHO needs to make to truly fulfil its mission and mandate. The first is that we must become much more focused on outcomes rather than simply outputs. WHO is known for the quality of its normative work, but there’s little value in publishing a guideline if nobody uses it. We need a much greater emphasis on making sure our world-class technical work is used at country level, and a much greater focus on measuring the impact of that work.

The second major shift flows from the first. If our mission is to ensure a measurable impact in health in countries, we must make sure that our 150 country offices have the resources they need to make a difference. In the past, WHO has been too Geneva-centric; we’re seeking to reshape WHO’s “operating model” to make sure everything we do supports what our country offices need to deliver impact.

Third, the global health architecture is very different now from what it was when WHO was founded 70 years ago, with many more actors with skills, experience, knowledge, networks and resources that WHO lacks. If we see this as a threat, it leads to territorialism and more silos. But if we see it as an opportunity, we can have a much greater impact than ever before. They key is to engage with partners proactively, harness everyone’s collective strength.

Finally, there’s little point in setting ambitious goals if they’re not matched by ambitious investments. We will soon be releasing our investment case, which describes what a fully funded WHO could achieve. But it’s not just the quantity of funding that matters; it’s the quality. One of the biggest threats to WHO’s long-term success is the earmarking of funds. So, we’re urging our Member States to support us with high-quality, flexible funding to enable to us make the biggest impact possible.

DP: You’ve made universal health coverage the central objective for WHO. Most people see UHC focusing on expanding access to effective health care, yet many new health concerns, such as climate change, food insecurity, and social and structural determinants of health go beyond traditional clinical care. What role should WHO have in getting the right balance between individual clinical care and public goods or collective action in health?

TAG: There’s an important distinction between universal health care and universal health coverage. The former is often used to refer to clinical services delivered by health workers in health facilities. The latter includes clinical services but is much broader: It also includes public goods that address the social, economic, occupational and environmental determinants of health, such as clean water and sanitation, road safety, efforts to reduce air pollution and so on.

Many of these are determined by policies that lie outside the health sector, so it’s vital that those of us in the health sector work across sectors to achieve health goals, such as working with the energy sector to improve reduce air pollution and climate change. In the same way, other sectors need to work with the health sector to achieve their own goals.

WHO’s five-year strategic plan, called the General Programme of Work, emphasizes our role in providing global public goods by enabling ministries of health to engage more effectively in inter-sectoral work. In practical terms, that means we engage high-level political advocacy, we get our hands dirty in country-level technical work, and we also monitor trends and provide information about the cost of inaction, enabling governments to adjust policies and creating citizen demand for healthier environments. All this is supported by the evidence-based guidance and tools that ensure that public health goods for health are managed and protected efficiently.

“The key is to engage with partners proactively and harness everyone’s collective strength.”

DP: Our understanding of health equity and universal health coverage has changed a lot since [the 1978 declaration at] Alma Ata. A lot of work being done on health equity is done in silos—focusing on delivering services in specific programs and not a more holistic or person-centered view of people’s health needs across the lifecycle. The research is also often disconnected to what governments are doing. What’s the role of WHO in bridging knowledge and practice gaps around equitable access to effective coverage?

TAG: Knowledge management and knowledge dissemination are part of WHO’s core business. A lot of research around the world is done by individual institutions with a focus on specific diseases; WHO has a critical role in shaping the research agenda (often raising issues that are underrepresented in traditional research financing), assessing knowledge, and translating and disseminating that knowledge in a way that governments can use to develop and implement policies. We also provide direct technical assistance to governments, translating that body of evidence to make a difference on the ground.

Health equity research plays a fundamental role in documenting health inequities and supporting countries to measure and improve health equity. WHO’s role is to support health equity research that is relevant to governments’ priorities for health policy and health system strengthening.

This work is led by the Alliance for Health Policy and Systems Research, an international partnership hosted by WHO. It involves an innovative model of research led directly by policymakers and embedded in real-world policy and practice. Equity is one of the key research areas for the Alliance. This new approach has helped to close gaps in immunization coverage and foster equitable access to reproductive health services in various low- and middle-income countries.

By promoting more relevant and demand-driven research, embedding health equity research has the potential to significantly improve health policymaking and inter-sectoral collaboration, with a view of progressing towards UHC and the Sustainable Development Goals.

DP: WHO was built on managing nation-state interests in health and wasn’t particularly designed to engage with civil society or the corporate and NGO sectors. Yet they are increasingly prominent actors affecting the public’s health. Do you see any changes for WHO in working with non-government actors?

TAG: It’s true that leveraging the strengths of civil society, the private sector, philanthropic foundations and academic institutions is essential for achieving the Sustainable Development Goals. Governments, public institutions, the UN system and multilateral agencies simply don’t have all the needed skills, knowledge, expertise or resources.

In fact, we are engaging even more proactively with civil society organizations and have invited them to suggest ideas on how we can work together more strategically and effectively. We’ve also established civil society working groups for tuberculosis and noncommunicable diseases in preparation for the high-level meetings on those two subjects at the United Nations General Assembly this year. We’ve met several times and those groups are working very well.

But it’s not right to say that WHO wasn’t designed to engage with non-state actors. WHO’s constitution, written in 1948, explicitly commits WHO to working with “any organization, international or national, governmental or non-governmental” to fulfil its mission and mandate.

The global health landscape has become more complex, with many more players involved in global health governance. To enable WHO to navigate that landscape, capitalizing on its strengths while minimizing its risks, our Member States led an intensive negotiation process that resulted in the adoption in 2016 of the Framework of Engagement with Non-State Actors, or FENSA. This unique instrument establishes the “rules of engagement”, and enables WHO to work with non-state actors while managing potential conflicts of interest, reputational risks and undue influence.

As part of our efforts to implement FENSA, we’ve developed a handbook to help non-state actors interact with WHO and a guide for staff to help them understand and apply the rules. We also maintain a register of non-state actors to ensure transparency and accountability.

DP: What’s most different in managing international politics from the role of a national leader to leader of a multilateral organization?

TAG: There are a couple of key differences. The first is that instead of making decisions based on national interest and other political considerations, WHO is an evidence-based institution that makes decisions according to what the science tells us.

The second major difference is that instead of one country with 100 million people, I now have to worry about 194 countries with 7.5 billion people. Of course, managing an organization with 8,000 staff in 150 countries is also no easy task. At one level that makes things much more complex, but it also means there is much greater potential for impact. I’m an optimist and I don’t think anything is impossible. There’s no other organization in the world with WHO’s global reach or broad mandate. The challenge we have is to make sure that we fulfill that mandate to the best of our ability. That’s what motivates me.

DP: Disease surveillance and response is a global public good that you’ve prioritized. What do you think WHO has learned from West Africa’s Ebola outbreak?

TAG: Not only WHO, but the whole global health and humanitarian community has learned a great deal and has made substantial progress to ensure the painful lessons of that outbreak are not wasted.

Keeping the world safe from health emergencies is one of three key priorities in WHO's five-year strategic plan, the General Programme of Work. We've set ourselves the ambitious goal of improving global health security, with 1 billion more people better protected from health emergencies. 

Building on the successful reforms begun under Dr. Margaret Chan, we’re redoubling our efforts to measurably increase the resilience of health systems based on WHO’s International Health Regulations. Those regulations focus on building core capacities to enable a rapid response at the source of an outbreak in every country in the world. 

In 2016 we established the new WHO Health Emergencies Programme. It was a profound change for WHO, adding operational capabilities to our traditional technical and normative roles. One of the lessons learned from West Africa is that disease outbreaks move faster than the money allocated to respond to them. As part of the Health Emergencies Programme, we set up a rapid response funding mechanism called the Contingency Fund for Emergencies (CFE) so that money is immediately available to jump-start an outbreak response. For example, when two separate Ebola outbreaks struck the Democratic Republic of the Congo this year, we were ready. Within hours of the first cases being confirmed, WHO allocated millions of dollars of emergency funding.

We've also set up an Emergency Medical Teams initiative to assist organizations and countries to build capacity and strengthen health systems by coordinating the deployment of quality-assured medical teams in emergencies. More recently, we’ve set up a mechanism with the World Bank to monitor and report on global preparedness to tackle outbreaks, pandemics, and other emergencies with health consequences.

DP: Since the Ebola outbreak, some have emphasized the need to develop strong human resources, physical infrastructure and systems to rapidly identify and respond to outbreaks. Others have emphasized community engagement and integrated clinical and public health approaches at the local level. Most of the post-Ebola effort has gone to the former, and not the latter. Is this how it should be?

TAG: It’s not an either-or equation; both are exceptionally important. The best way to prevent outbreaks is to invest in stronger health systems that are oriented towards achieving universal health coverage. I often say that UHC and health security are two sides of the same coin. At the same time, community engagement is critical to an effective outbreak response. That was one of the big lessons learned from the West African Ebola outbreak, where effective community engagement helped turn the corner in the response.

Today, WHO sends community engagement specialists and anthropologists out to the field during an outbreak response just as quickly as we send epidemiologists and clinical care specialists. It’s critical to know and understand communities in order to effectively work with them in all phases of an emergency, from preparedness to response to recovery.

DP: What should schools of public health be doing differently? What role do you see for universities in working with WHO? Are there new opportunities for collaboration?

TAG: WHO values the immense contribution of schools of public health to the education of global health advocates, leaders and practitioners, the generation of evidence, and collaborations to deliver innovative solutions for modern health challenges. But we can always do more, and we can always do better—we need more collaboration between universities, communities, health systems and practitioners to generate and share intelligence.

We need to identify and advocate for and with communities for solutions to tackle the health issues of greatest impact, with the most effective and efficient use of resources.

Collectively, we need to grow public health leaders with skills in policy analysis and advocacy, to ensure decision-makers have the tools to affect real change. We also need to work harder to establish the case for investment in human resources in every country to achieve UHC and the SDGs.

Public health professionals play a vital role in advocating for universal health coverage and the health systems that deliver it, and in strengthening countries’ capacities to respond to emergencies in a holistic and sustainable way.

Just as capable health professionals are vital to the health of an individual, we need capable health managers, human resources scientists, planners and policy-makers to attend to the health of entire systems, all backed up by stronger evidence.

To have the greatest impact, those of us working in public health must stay aligned and consistent in our efforts to ensure the translation of knowledge into action.

We encourage universities to engage with the Global Health Workforce Network, which has established seven thematic “hubs” for sharing intelligence to take forward the actions of the 2016 Global Strategy on Human Resources for Health and the recommendations of the High-Level Commission on Health Employment and Economic Growth. The hubs relate to gender equity, youth, education, data and evidence, health labor markets, community-based health workers and human resources leadership.

Editor's note: This article first appeared in Global Health NOW: Parts 1 and 2.