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The process of choosing the next director-general of the World Health Organization starts in earnest this week. While the final selection won’t be made until May, the current field of six will shrink to five, then no more than three before the week is out.

If you haven’t been paying much attention up until now, you’re not alone. With Brexit and the US election, this campaign has been getting little attention.

So let’s explore the three Ps — the people, the process, and the predictions.


Who wants to lead the WHO?

Four Europeans, one African, and one South Asian are vying to succeed Dr. Margaret Chan, whose second term as WHO director-general ends on June 30. (Directors-general can only serve two five-year terms. Chan, who was nominated by China, served a little longer because her predecessor, J.W. Lee of South Korea, died before his term ended.)

All but one of this year’s candidates is a medical doctor. Four have served as health minister for their respective countries and two of those four have also served as foreign minister. Two have had extensive WHO experience. Most have done work for global institutions — the United Nations, the World Bank, UNICEF, or prominent players in the global health sector such as Roll Back Malaria and Gavi, the Vaccine Alliance.


The candidates are:

  • Tedros Adhanom Ghebreyesus, 51, from Ethiopia. Tedros (he goes by his first name), who was until recently foreign affairs minister, and health minister earlier in his career, is the only non-physician; he has a PhD in community health.
  • Dr. Flavia Bustreo, 55, from Italy. Bustreo is WHO’s assistant director-general for family, women’s, and children’s health (on leave while she campaigns). She has also worked at UNICEF and the World Bank.
  • Dr. Philippe Douste-Blazy, 64, of France. A former health and foreign affairs minister, he founded UNITAID, which works to prevent, diagnose, and treat HIV.
  • Dr. David Nabarro, 67, of Britain. Nabarro has spent much of his career at the WHO and then the UN. He is currently the special adviser to the UN secretary general on sustainable development and climate change.
  • Dr. Sania Nishtar, 53, of Pakistan. A former health minister, Nishtar has extensive experience both nationally and internationally in the civil society sector.
  • Dr. Miklós Szócska, 56, from Hungary. Szócska is a former health minister, and a professor in the Health Services Management Training Centre, at Semmelweis University in Budapest.

How does this election work?

The first few steps in this process are taken by the WHO’s executive board, which holds its annual meeting in Geneva this week. It is composed of representatives from 34 countries who are elected to serve on the board for three-year terms.

The United States currently has a seat on the executive board, held by Dr. Tom Frieden, who until Friday was director of the Centers for Disease Control and Prevention. He was not asked to stay on by the incoming Trump administration.

The US government has not made public who it is backing in this race and Frieden will not say for whom he’s been instructed to vote. “That is confidential,” he told STAT in an email.

Voting throughout this process will be done by secret ballot, a decision some observers have criticized.

On Tuesday, the executive board will vote to select a short list of five candidates who will be interviewed Wednesday. The interviews — one hour per candidate — will be held behind closed doors. Canada and Colombia have put forward a motion to make the interviews public, but it was not accepted.

After the interviews, executive board members will pare the list of candidates down to no more than three. The finalists will continue to campaign until the World Health Assembly — the WHO’s annual general meeting — in May, when the 194 member states will elect Chan’s successor. He or she will take office July 1.

Anyone want to place a bet?

If you’re tempted, you may not find someone to take it.

“I do think the outcome is going to be unpredictable,” Suerie Moon, director of research at the global health center of the Graduate Institute of International and Development Studies in Geneva, told STAT. “Everybody has their hunch. But I haven’t spoken to a single person who thinks they know or will admit that they know.”

Many observers are skeptical that Szócska will make it to the interview stage. His CV is thinner than those of his rivals.

After that, it becomes much harder to forecast. Voting for a position like this involves backroom diplomacy and often, frankly, horse-trading — things that are impossible to track with secret ballots and when few if any countries openly declare their preference.

Another factor adds to the opacity: When voting on the final three, board members will have three votes apiece. The system may have been devised to try to ensure that the three strongest candidates go forward to the final round, but observers are not so sure things will work that way.

Some countries may choose to cast one vote for the person they hope will win, and use the other two to strengthen his or her chances by supporting weaker candidates to knock out their favorite’s strongest rivals. Or the executive board as a body might favor a candidate, and nominate that person plus two weaker candidates — putting its thumb on the scale, essentially.

Who would be best for WHO may not be top of mind. “I would be highly skeptical that that is the driving force behind voting decisions,” said Moon. “I think countries will vote based on strategic calculations.”

While the outcome is uncertain, there are a few tea leaves in the bottom of the cup.

For a while, the word in international circles was that it was Africa’s turn; an African has never led the WHO. And though a number of potential African candidates tested the waters early on, only one emerged. Early last year, the African Union said all African countries were supporting Tedros. That would make a 54-country bloc for him if he makes it to the final three. But only eight African Union countries are on the executive board. And rumors have swirled for months that France has pried away some African support for Douste-Blazy, for whom France has been campaigning hard.

Having four candidates from Europe doesn’t help any of them, as it likely splits what might otherwise might have been a significant bloc. Likewise, Britain’s departure from the European Union may cost Nabarro — who on experience alone would appear to be one of the strongest candidates. “I imagine that Brexit isn’t helping David Nabarro,” Moon said.

It’s also not clear, given the appetite for change manifested in the Brexit vote and the US election, whether being a WHO insider is an advantage at this point. That said, Moon noted that none of the five expected to go through to the interview round could be seen as a true outsider.

She wouldn’t make a prediction on who will win this race — or even who will be in the final three. But Dr. Ashish Jha, director of the Harvard Global Health Institute, said he thought Douste-Blazy, Tedros, and either Nishtar or Bustreo would be the candidates who make it through to the final voting round.

Watch this space.

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