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The 70^th annual World Health Assembly (WHA), now underway in Geneva, is shaping up to be one of the most consequential in memory. With a record-setting nine-day, 76-item agenda, plus dozens of official and unofficial side events, delegates and WHO followers alike will be hard-pressed to keep up. But yesterday’s introductory briefing, hosted by the Global Health Centre at the Graduate Institute, provided an overview of the proceedings and a few pointers on where to look first. Four items, in particular, stand out.

Director-General Election (Tues, 23 May; Agenda Item 4, for those following at home)

Every five years, WHO Member States elect a Director-General. But this year’s election is path-breaking in several respects. First, WHA delegates have a genuine choice to make. DG candidates are nominated by their home countries and then vetted and voted on by the WHO Executive Board (EB, comprised of a subset of Member States, with seats allocated by region). In the past, the EB has forwarded a single nominee to WHA for approval, effectively turning the WHA vote into a rubber stamp. But this year, for the first time, the EB has advanced three candidates: Sania Nishtar (Pakistan), David Nabarro (UK), and Tedros Adhanom Ghebreyesus (Ethiopia). Although Tedros is considered the favorite, DG elections are closed ballot and beset by horse trading, meaning anything can happen. Gian-Luca Burci, formerly WHO Legal Counsel and now a Professor at the Graduate Institute, reminded that multiple rounds of voting may be necessary; and since a new electronic voting system failed testing, the 194 votes will be cast on paper ballot and counted by hand. In other words, Tuesday may be a long day.

The DG election is also notable for the unprecedented level of transparency and accessibility with which it has been conducted. For the past nine months, candidates have met privately with Member State governments and the EB, as usual. But there has also been a robust public campaign and debate. Candidates have spoken in open forums and given numerous media interviews; the three final candidates participated in a public debate at the Graduate Institute in March. While disagreements remain about the virtue of open vs. closed ballots, there is no doubt that the DG election is now the most open process of its kind and can serve as a model for other UN agencies and global health organizations.

At press time, the WHO released the following information about the election:

“Tomorrow, Tuesday 23 May, the three nominees for the post of Director-General of WHO will each make a 15-minute presentation to the World Health Assembly. The session will start at 2 pm, (Central European Summer time).

The presentations can be watched via live webcast at: http://who.int/mediacentre/events/2017/wha70/webstreaming/en/

The order of speakers, as decided at the World Health Assembly Plenary today, is as follows:

Tedros Adhanom Ghebreyesus
David Nabarro
Sania Nishtar

More information on the election of the Director-General of WHO can be found here:”
http://who.int/dg/election/en/

2018-2019 Program Budget (Agenda Item 11)

The second biggest item on the agenda is the adoption of a new program budget. Every two years, WHA approves a program budget which apportions funding to WHO’s six core programmatic areas (plus polio eradication and other special programs). Perhaps more importantly, it also specifies how much funding will come from assessed contributions (i.e. mandatory contributions from Member States, which are allocated by the Secretariat in accordance with Member State priorities and approved by WHO) and how much from voluntary contributions (i.e. donations made by state and non-state donors, which are generally earmarked in accordance with donor priorities).

At present, roughly 80% of WHO’s funding comes from voluntary contributions. Ian Smith, Executive Director of the DG’s Office, points out that this creates a number of challenges for the organization, not least an accountability problem. On the one hand, WHO’s mandate is set by Member States collectively. On the other hand, WHO can only do what it is actually funded to do, which depends on the interests of a handful of major donors. For example, Member States consistently rank addressing non-communicable diseases as their #1 health concern, but this is one of the programmatic areas in which WHO has the most difficulty securing donor funding.

The most obvious remedy for this dilemma is to raise the level of assessed contributions so that WHO has more money to direct towards addressing Member States’ collective priorities. In January 2016, the UN High-Level Panel on the Global Response to Health Crises (convened in the wake of the disastrous Ebola response) recommended that assessed contributions be increased by at least 10%. The WHO Secretariat incorporated this 10% increase (equating to US$93 million) into the budget proposed to the EB in January of this year. After much debate among Member States, that requested increased was reduced to 3% (or approx. US$28 million, for the 2018-2019 biennium only). According to Ian Smith, the Secretariat is “quietly confident” that this budget will pass.

Polio Transition Planning [Agenda item 12.3]

WHO’s budget problems have been simmering for a couple of decades, but there is a potential tsunami on the horizon. Polio eradication is finally within sight, so much so that WHO has begun to plan for the aftermath. Polio eradication will be a monumental global health achievement. But it will also have monumental—and potentially injurious—consequences for WHO and for health service delivery in countries targeted by eradication efforts. The Global Polio Eradication Initiative (a partnership of WHO, Rotary International, the US Centers for Disease Control, and UNICEF; later jointed by the Gates Foundation) is the single largest global health initiative in history. It has received over US$14 billion in funding since 1985. Anne Marie Worning, Advisor to the Director General on Polio, reports that much of this funding is used to cross-finance other health activities, with 25% of dollars spent by WHO in 2016 came from polio funding. More than 1,000 WHO staff positions, as well as over 6,000 non-staff members in Africa and Southeast Asia (e.g. community health workers) are paid using polio funds.

What will happen if those funds disappear with the polio virus? Worning points out that at the national and sub-national level, these workers are involved not only with polio eradication efforts, but with other immunization activities, emergency response operations, maternal and child health services, and neglected tropical disease programs. Eliminating their positions would cripple health service delivery and undermine efforts to strengthen health systems. Other health initiatives would become more expensive; for example, Worning reported that deworming programs would cost 30x more if they could not make use of the polio eradication infrastructure. And national health budgets would likewise feel the pinch; for example, Ethiopia would lose US$34 million in funding over three years (going from $39 million to $5 million). Since many of the affected countries are simultaneously transitioning out of eligibility other major funding source (e.g. Gavi, the Global Fund), the combined impact could well be “catastrophic”.

As instructed by a Jan 2017 Executive Board resolution, the Secretariat is in the process of developing a transition plan, which will be presented for Member State feedback at WHA. Other initiatives are underway to ensure that affected countries develop their own transition plans, and that the systems and capacities so painstakingly built for polio eradication do not erode away. But although planning is crucial, in some ways, WHO’s hands are tied—what happens post-polio will depend on what donors decide to with their money. So the primary contribution of polio transition planning discussions at WHA may be calling attention to just what is at risk.

Access to Medicines & Other Cross-Cutting Issues [Agenda items: 13.3-13.6 & 15.3, inter alia]

Some of the most important issues to be discussed at the WHA, including health and the SDGs, universal healthcare and access to medicines, cut across issue areas. Suzanne Hill, Director of the Essential Medicines and Health Products Department at WHO, identifies at least six relevant agenda items, including those on research & development, financing, substandard & falsified medical products, drug & vaccine shortages, and access to cancer treatment. While this fragmentation is partly due to the ever-expanding list of issues addressed at the WHA, it also comes about as a result of shifts in how issues are understood. Hill points out that whereas access to medicines used to be viewed primarily as a problem in developing countries, high prices and shortages are increasingly affecting developed countries as well. This creates new potential for countries and issues to come together. But it also makes it easier for things to fall apart. Cross-cutting issues complicate negotiations since it is difficult to reach a consensus in one drafting group or on one agenda item, when the terms of agreement will be affected by the outcome of discussions on another agenda item or in another drafting group. And on Day 1 of the longest, most jam-packed WHA ever, the last thing needed is more complicated negotiations.

Mara Pillinger is a PhD candidate at George Washington University. Follow her on Twitter @mplngr.