UNAIDS executive director Winnie Byanyima (centre) and Programme Co-ordinating Board (PCB) chair Ambassador Erica Schouten (left) at the special meeting to decide on the way forward for UNAIDS.

The UNAIDS Programme Coordinating Board (PCB) has rejected the proposal by the United Nations Secretary-General that it is “sunsetted” by the end of this year, opting instead to transform into a smaller “hub”.

This emerged after the PCB’s special meeting on Monday, which considered a report by a working group on the body’s future. The working group recommended that the body is transformed into a much smaller, more focused body rather than sunsetted in the next few months.

“You have rejected the sunsetting of UNAIDS and chosen instead to transform and strengthen this unique joint programme,” said UNAIDS Executive Director Winnie Byanyima in a statement issued on Tuesday.

“I thank programme countries, donors, civil society and activists who stood firm and fought for the future of UNAIDS. Saving the joint programme is only the beginning. Now we must transform it and get that transformation right.” 

The board has charged the executive director with establishing a “transition task team, comprising secretariat and cosponsor representatives and two community representatives nominated by the PCB NGO delegation”, according to a UNAIDS media release. 

“The team will work closely with implementing countries, consult relevant joint programme stakeholders and be accountable to the board for delivering a fully costed implementation plan.”

However, Byanyima’s term ends at the end of December, so the UN Secretary-General will need to appoint an interim replacement to manage the transition process. 

PCB chair Ambassador Erica Schouten, the Netherlands representative to the UN in Geneva, has been tasked with reporting the UNAIDS decision to the United Nations Economic and Social Council (ECOSOC).

The UN is facing a dire funding shortage, and its proposal to “sunset” UNAIDS was part of its cost-cutting plan. 

Tighter secretariat

The working group proposes a strong and focused secretariat (or “hub”) to lead the UN’s HIV work in four core functions: leadership and advocacy; convening and coordination; accountability, data and targets; and community support.

The secretariat will provide cross-cutting leadership for the Global AIDS Strategy, which aims to end AIDS by 2030. It will also coordinate UN joint action on HIV, and data and accountability for meeting global AIDS targets. 

Meanwhile, UNAIDS presence in affected countries is expected to evolve over time, with the aim of integrating country-level functions into national institutions.

However, the Joint Programme will “need to have a clear presence in all regions to carry out functions that are performed more efficiently at this level, such as monitoring and evaluation support, facilitation of south-south learning, technical or crisis capacity, and engagement with political and technical bodies, the working group notes”.

UNAIDS has already slashed its global staff from 608 to 294, with only 19 located at its large headquarters in Geneva. The remaining UNAIDS secretariat staff are currently employed across these four core functions, and around two-thirds of staff are located in sub-Saharan Africa. 

Staffing accounts for 55% of the secretariat’s 2026 budget of $ 85.1 million, with 39% devoted to activities.

Bigger role for co-sponsors

A central pillar of the transformation of UNAIDS rests on its co-sponsors – 10 UN agencies and the World Bank – taking “stronger leadership in technical areas”. 

The working group report notes that the co-sponsoring agencies have “expertise in diverse sectors and a presence in more than 130 countries” and should be “the primary implementer of the UNAIDS Joint Programme’s technical work”. 

It recommends “ceding all technical and programme implementation functions to the co-sponsors”, proposing that they be mandated to “take leadership of the individual result areas of the Global AIDS Strategy”.

The working group report also notes that four co-sponsors employ dedicated HIV staff, including the World Health Organization (117 HIV-focused staff), UN Population Fund (75), UN Development Programme (74), and UN Children’s Fund (more than 60). 

A pool of funding will be maintained to support co-sponsor-led and co-sponsor-facilitated work at country level. 

The working group also notes that functions that require proximity to communities living with, and affected by, HIV should be led by community and civil society actors.

Areas of uncertainty 

However, there are still issues to be worked out. The working group noted that its members had “differences of opinion” over “the optimal length of the transition process; whether the UNAIDS Joint Programme should retain a standalone country presence or be fully integrated into existing UN or national-level institutions; and whether budgeting should be function-led or made to fit within an agreed funding envelope.”

It also notes that stakeholders “expressed divergent opinions as to whether a new executive director should be named or an interim director should manage the transition, with a permanent executive director named thereafter.”

Rubbish-laden trucks queue along a muddy access road at Pugu Kinyamwezi dumpsite in Dar es Salaam, where the disposal of the city’s waste poses environmental and public health challenges.

DAR ES SALAAM, Tanzania — The smell of burning garbage wafted into Ester Kayombo’s bedroom, jolting her awake with the fear that her house was on fire.

Nearby, heaps of rubbish were burning at the Pugu Kinyamwezi dumpsite, sending plumes of smoke billowing across the neighbourhood.

Kayombo, a mother of three, feared for her three-year-old daughter, Eliza, who has asthma. She wedged a wet cloth under the door and opened a rear window, hoping to clear the smoke. She clutched Eliza’s inhaler and listened anxiously as her daughter breathed.

“The smoke was so thick that my daughter struggled to breathe,” Kayombo said.

Kayombo, a street cook selling Ugali, rice, beans, meat and vegetables near the Pugu cattle market, is not considering leaving the house despite frequent fires, smoke and the strong smell from the dumpsite. 

Like millions of poor city dwellers across Sub-Saharan Africa, she faces a difficult choice between environmental health hazards and economic survival.

“My landlord is very kind. If I’m late paying the rent, he understands,” she told Health Policy Watch. “I rely on this market for my livelihood. I have nowhere else to go.”

Governance failure

The Pugu Kinyamwezi fire burned for a week, engulfing the impoverished neighbourhood in smoke. Firefighters struggled for days to control the blaze. A senior firefighter, speaking on condition of anonymity, revealed the critical operational deficits facing emergency services. 

“We don’t have enough water tankers, fire retardant foam, and protective gear for longer chemical fire exposure,” he told Health Policy Watch.

Over six million people live in the city, one of the fastest growing on the continent. Many people live in informal settlements, and there is a serious waste management crisis. 

The city produces roughly 5,600 tonnes of waste daily, but less than 40% is formally collected, according to Dar es Salaam City Council Statistics. Across crammed neighbourhoods, trash – including food and plastic bottles – often litters the streets, clogging drains and increasing flood risk in the rainy season.

The Pugu Kinyamwezi dumpsite sprawls across 65 hectares and receives about 2,500 tonnes of mixed rubbish a day, which is beyond its capacity.

“We receive more rubbish than we can handle. Food waste and organic matter release methane, which often causes fires in the dry season,” said Philip Benno, head of the City Council’s Waste Management Directorate. 

Benno said the government is seeking investors to modernise the dump, aiming to turn it into a sanitary landfill that is capable of generating energy from waste. 

However, policy analysts say progress has been stalled by regulatory hurdles and delayed public-private partnership (PPP) frameworks.

Philip Benno, head of the Dar es Salaam City Council’s Waste Management Directorate, at the Pugu Kinyamwezi dumpsite in Dar es Salaam. Poor waste management and smoke from dumpsite fires are affecting the health of surrounding communities.

Air quality data

Burning mixed municipal waste releases fine particles, heavy metals and toxic gases into the air, environmental health experts say.

A study by researchers from the Dar es Salaam Institute of Technology and Stockholm Environment Institute analysed measurements from 14 monitoring stations between May 2021 and February 2022. 

Daily average concentrations reached up to 130.45 micrograms per cubic metre (µg/m³) for fine particles (PM2.5), and 184.15 µg/m³ for the coarser PM10.  

The monitoring station at Pugu ‘Dampo’ recorded the highest pollution levels. The peak PM2.5 reading was almost nine times WHO’s 2021 guideline of 15 µg/m³ over 24 

“While our study did not collect direct patient data, the measurements clearly showed concentrations several times above WHO safe limits,” said Jacqueline Senyagwa, an SEI researcher and co-author of the study.

Health impacts 

Globally, air pollution causes 7.9 million premature deaths annually, with over 90% occurring in low- and middle-income countries, according to the World Health Organisation. 

Aside from the human toll, the World Bank estimates that air pollution costs the global economy nearly 5% of global GDP, and targeted policies could lower the number of people exposed to dangerous levels by 2040, with economic benefits of up to $2.4 trillion.

At the local level, health facilities bear the direct brunt of pollution spikes.

“During landfill fires, we see a rise in paediatric outpatient visits for acute asthma attacks, bronchitis, and upper respiratory tract infections,” said Dr Daniela Tarimo, a physician at Kivule District Hospital. 

“Children are disproportionately vulnerable because their lungs are still developing and they breathe more air per kilogram of body weight than adults.”

Local clinics report that stocks of basic bronchodilators and paediatric nebuliser kits often run dangerously low during extended fire episodes, leaving low-income families to purchase medications out-of-pocket at commercial pharmacies.

More than a third of respondents reported burning their rubbish in a survey of 217 households in Dar es Salaam’s Tandale, Manzese and Tandika wards, exposing a gap in waste disposal services with implications for public health. 

The study, by Felician Andrew Kitole and colleagues, found that 61% of households had no access to waste collection services. As a result, 35.9% burnt their waste, and 41.9% used open dumpsites. 

Respiratory infections were reported in 14% of households, which researchers linked to waste burning and poor air quality. Other illnesses included diarrhoeal diseases (39% of households), malaria (28%), typhoid (9%), skin infections (5%) and cholera (3%). Researcher linked these conditions with some of the consequences of poor waste management, including contaminated food and water, stagnant water that provides mosquito breeding sites, and contact with polluted materials.

The authors recommended more frequent rubbish collection, community-led waste programmes and subsidised bins and waste bags. However, the study captured conditions at a single point in time, and did not establish how many people across Dar es Salaam were affected by waste-burning pollution or prove that burning caused the reported infections.

Struggling with rubbish 

Municipal workers negotiate waterlogged ground between heaps of mixed rubbish at Pugu Kinyamwezi dumpsite in Dar es Salaam. The accumulated waste highlights the scale of the city’s disposal challenge.

Environmental experts say dumpsite fires are caused by deliberate or accidental burning, flammable materials and heat generated by organic waste.

Zainabu Katima, who lectures in environmental sanitation at the University of Dar es Salaam’s College of Engineering and Technology, said household rubbish, discarded plastics and rubber can cause hard-to-control fires.

“When different types of waste are dumped together without being sorted, a small fire can spread quickly,” she told Health Policy Watch.

The WHO links air pollution to heart disease, stroke, chronic obstructive pulmonary disease and lung cancer. Fine particles can travel deep into the lungs and pass into the bloodstream.

“When plastics and other synthetic materials burn with household rubbish, they can release fine particles and harmful gases into the air,” said Regina Kilima, an environmental health researcher at the National Environmental Management Council

For children with asthma, such as Eliza, smoke exposure can worsen symptoms and trigger severe breathing difficulties.

Weak monitoring

Tanzania has environmental laws and air quality regulations, but limited monitoring and overlapping institutional responsibilities hamper pollution control, experts say.

Despite weak enforcement, poorly coordinated oversight, and a lack of pollution monitoring equipment, community groups in Dar es Salaam are devising their own mechanisms to tackle air pollution.

In the densely populated Kimara neighbourhood, the Tanzanian environmental organisation, Nipe Fagio (Swahili for “Give Me a Broom”), has organised women to collect household waste and separate organic matter, recyclables and hazardous materials. The work provides income and reduces the amount of waste sent to dumpsites.

It supports Zero Waste cooperatives, made up of waste pickers, women and youth, that generate income from collecting waste, recyclables, maggot farming, composting and urban farming.

“Community initiatives prove that sorting waste at home is possible, but we need municipal-scale investments to bridge the gap,” said Wilyhard Shishikaye, a coordinator with Nipe Fagio.

Nipe Fagio trains waste pickers to recycle waste through Zero Waste cooperatives.

Making clean air a public health priority

Health policy experts are calling on Tanzania to expand air pollution monitoring in urban areas and make the readings publicly available. They also recommend upgrading open dumpsites such as Pugu Kinyamwezi into sanitary landfills with proper waste handling and methane collection systems.

This would require environmental regulators, local councils and health authorities to work more closely together. Experts say the National Environment Management Council and councils need the staff, equipment and funding to enforce restrictions on waste burning. Health centres also need clear procedures for treating patients with breathing difficulties during severe pollution episodes.

Residents living near garbage dumps need to receive timely warnings about fires and clear advice about how to reduce their exposure to smoke and access to medical care.

Their ability to protect themselves often depends on what they can afford. Some families may be move away, but many cannot afford to. 

For Ester Kayombo and her daughter Eliza, structural reforms cannot come soon enough. As long as urban waste management remains underfunded, the burden of toxic smoke will continue to fall heaviest on those unable to escape it.

Image Credits: Zuberi Mussa, Nipe Fagio.

C02 levels have reached record highs in the atmosphere, according to the latest WMO bulletin.

The levels of major greenhouse gases reached record highs in 2025, locking in more long-term temperature rise for the planet, according to a new bulletin from the World Meteorological Organization (WMO).

Among the greenhouse gases, the levels of carbon dioxide (CO2) and methane (CH4) continue to dominate.

In its latest Greenhouse Gas Bulletin, the WMO reported that the globally averaged surface concentration of CO2 in 2025 was 426.8 parts per million, or 153% of the 1750 pre-industrial baseline.

“Another year, another new record. Greenhouse gases are trapping an unprecedented amount of heat in the atmosphere, providing energy for more extreme weather and associated risks to our economies and societies,” said WMO Deputy Secretary-General Ko Barrett.

“The past 11 years have been the warmest on record, and this trend is set to continue. CO2 has a very long lifetime and so will affect the global climate not just for years but for decades and even centuries.”

Concentrations of nitrous oxide, the third most important long-lived greenhouse gas related to human activities, also rose to a new record.

In the summer of 2025, over 50,000 people died from heat in Europe, the region heating fastest in the world, according to a recent study published in Nature.

Researchers used statistics from 854 European cities from heat waves in June, July and August, and found that 50,391 people died from warmer temperatures, and that “68% of the estimated heat-related deaths in 2025 were attributable to human activity”.

Global leaders are set to meet in Antalya, Türkiye, in November to once again seek to turn climate commitments into concrete actions at the annual UN climate conference COP, now in its 31st year.

CO2 growth rates tripled

Globally averaged CO2 concentration (left) and its growth rate (right) from 1984 to 2025. Observations from 179 stations were used for this analysis.

Growth rates of CO2 have tripled since the 1960s, accelerating from an annual average increase of 0.8 ppm per year to 2.4 ppm per year in the decade from 2011 to 2020. From 2024 to 2025, the global average concentration of CO2 rose by 2.8 ppm – above the decadal average but slightly less than the exceptional surge of 2023-2024.

“The more modest growth rate from 2024 to 2025 reflects recovery of the land carbon sinks and reduced fire carbon emissions in 2025 after the strong 2023-2024 El Nino, which reduced the efficiency of the biosphere through more drought, drier vegetation and more wildfires,” said WMO senior scientific officer Oksana Tarasova.

Nearly half of the CO2 released in the atmosphere is absorbed by the water bodies and land sinks like forests and wetlands.

“However, a 2.8 ppm annual increase is still a substantial addition of carbon to the atmosphere from fossil fuel burning. We can expect to see a further increase in concentrations in 2026 because of fossil fuel burning and the development of a powerful El Niño which will impact land carbon sinks as it did in 2023-2024. The risks of reduced CO2 uptake by the ocean are also increasing in our changing climate,” Tarasova said.

Other greenhouse gases are also rising

Contribution of the most important long-lived greenhouse gases to the increase in global radiative forcing from the pre-industrial era to 2025.

Currently, methane accounts for about 16% of the warming effect on our climate by long-lived greenhouse gases, but it has a much shorter lifetime than CO2.

Around 35% of methane is emitted into the atmosphere by natural sources (for example, wetlands) which are sensitive to climate as well, and about 65% comes from anthropogenic sources such as cattle, rice farming, fossil fuel exploitation, landfills and biomass burning.

Global efforts are on to reduce methane emissions, especially in the agriculture sector.

The bulletin also warns countries to pay careful attention to two potent but less abundant trace gases closely related to electricity production and distribution: molecular hydrogen (H2) and sulphur hexafluoride (SF6).

The increase in SF6 in 2025 was a record high. It has been rising steadily over the past three decades in proportion to increased global electrification, since SF6 is used primarily as a spark suppressant in electricity distribution. It has an atmospheric lifetime of over 1,000 years, and its 100-year global warming potential is approximately 24,300 times that of CO2.

Hydrogen concentration has also increased by 5.3% between 2010 and 2024. Hydrogen is being used as an energy storage medium for hard-to-decarbonize sectors such as steelmaking, shipping, and long-duration energy storage, as well as for renewable sources and as an energy source for transport.

Its leakage into the atmosphere from production facilities, pipelines, storage tanks, and fuel cells poses a growing concern. Hydrogen is not a greenhouse gas, but it influences atmospheric chemistry and so has a strong indirect effect on warming.

Image Credits: WMO, WMO.

Who will steer the World Health Organization through its next chapter? Explore Health Policy Watch’s daily series examining the platforms, records, and institutional hurdles facing each contender for WHO Director-General, continuing today with Song Li. Access all candidate profiles on our dedicated election site.

Framed by Beijing as advancing a “community of health for all”, Song’s prospective platform will likely centre on primary care and South-South cooperation.
Framed by Beijing as advancing a “community of health for all”, Song’s prospective platform will likely centre on primary care and South-South cooperation.

The formal confirmation of Dr Song Li’s candidacy by the People’s Republic of China on 8 October expands the official election field for WHO Director-General to seven candidates, following an initially tight-lipped rollout by Beijing. Her bid introduces into the race a senior public health administrator and physician-scientist whose two-decade career at China’s National Health Commission (NHC) has centred on scaling primary healthcare, maternal and child health, and integrated disease prevention.

Her nomination fundamentally reshuffles the candidate field amid escalating US-China superpower competition, a geopolitical backdrop underscored by her political role on the Secretariat of the Communist Party-led All-China Women’s Federation (ACWF).

While Song has not released a standalone campaign manifesto, China’s Ministry of Foreign Affairs framed her bid around reinforcing multilateralism upon confirming her candidacy. Outlining her administrative record in a subsequent written response to Health Policy Watch, the country’s Permanent Mission in Geneva stated: “She has a strong track record of translating policies into concrete actions, with demonstrated capabilities in strategic leadership, policy development, programme implementation, organizational management and cross-sectoral coordination.”

Prospective programmatic framework

Speaking at the 2023 WPRO hearing, Song Li outlined her vision prioritising equitable health emergency response, and primary care delivery.
Speaking at the 2023 WPRO hearing, Song Li outlined her vision prioritising equitable health emergency response, and primary care delivery.

In the absence of a formal campaign manifesto, Song’s prospective platform can be anticipated across four core public health pillars – drawn from the Mission’s statement, her administrative background at the NHC, and disclosures from her unsuccessful 2023 campaign for Western Pacific regional director:

  1. Primary healthcare and maternal-child health equity: Grounded in her decades long record contributing to national maternal and child health programmes at the NHC, Song’s prospective platform is expected to prioritise primary healthcare (PHC) as the core engine for Universal Health Coverage (UHC). Her field leadership – which included scaling hospital delivery subsidies to 100 million rural women and advancing mother-to-child disease elimination – reflects a long-standing domestic emphasis on strengthening frontline community health services to reduce geographical and economic barriers for vulnerable populations.
  2. Healthy ageing and NCD prevention: Addressing rapid demographic change and non-communicable diseases in her 2023 WPRO bid, Song rejected viewing ageing as an economic liability, advocating instead for “elderly-friendly societies, communities, and hospitals.” Her technical background highlights life-course prevention – integrating NCD management directly into primary care systems to “turn silver into gold” through healthy longevity.
  3. Pathogen Access and Benefit-Sharing (PABS): Drawing on her two decades leading national health administration and epidemic response (SARS, COVID-19 protocols), Song explicitly aligned herself with calls to strengthen global health security governance through the Pandemic Agreement. Her record corresponds with Global South demands in the PABS negotiations for mandatory benefit-sharing and equitable access to emergency countermeasures.
  4. South-South cooperation: Having contributed to the China-Africa Health Cooperation Framework through its Women and Children’s Health Action Plan, and worked on Belt and Road health cooperation, Song brings a record that directly reflects Beijing’s health diplomacy and expanding soft-power footprint. This points to a prospective platform centred on country-led health capacity. During her 2023 candidate remarks, she emphasised moving away from donor dependency toward sustainable national self-reliance, supporting regional laboratory networks, local vaccine and diagnostic manufacturing, and costed national health plans.

This profile extends beyond her individual technical record. Her candidacy is fundamentally anchored in China’s active steering of broader institutional restructuring. As co-chair of WHO’s Joint Task Force on Global Health Architecture Reform alongside Germany, Beijing has positioned itself as a direct architect of future governance, institutional realignment, and multilateral funding mechanisms.

From clinical care to national public health

Shandong University’s Central Campus in Jinan. Song trained in obstetrics and gynaecology at the institution’s medical school before entering national public health.
Shandong University’s Central Campus in Jinan. Song trained in obstetrics and gynaecology at the institution’s medical school before entering national public health.

Born in 1974, Song began her career in clinical medicine, earning a Master’s degree in Obstetrics and Gynaecology from Shandong Medical University (1997-2000) and practising in gynaecologic oncology. Seeking to address systemic disease drivers at population scale, she transitioned to public health policy, joining the Ministry of Health (now the National Health Commission) in June 2002 as a programme officer in the women’s health division.

Her early administrative career was quickly defined by crisis management and academic accomplishments. During the 2003 SARS outbreak, she served in the national Emergency Operations Center, and following the 2008 Wenchuan earthquake in Sichuan Province, she led an on-site medical emergency team to oversee post-disaster maternal healthcare reconstruction. While advancing through the ministry, she deepened her technical credentials, completing a PhD at Peking University (2006-2010) alongside a visiting scholarship in global health at Harvard University in 2010.

During the COVID-19 pandemic, Song authored national protection protocols for pregnant women, published national guidance Q&As for maternal care, and facilitated international experience-sharing with global health partners. Her two-decade ascent through the ministry culminated in March 2021 with her appointment as Director-General of the Department of Women and Child Health, where she directed national strategic policies, legislation, and public budgets.

Building maternal care and national programmes

Beyond acute emergency response, Song’s domestic legacy centres on converting targeted interventions into permanent primary healthcare infrastructure. Her signature operational initiative directed hospital delivery subsidies to 100 million rural pregnant women.

According to official Chinese statistics, this initiative raised rural hospital birth rates from under 50% to over 99%, driving national maternal mortality down to 15.7 per 100,000 live births in 2022 – well ahead of the global UN Sustainable Development Goal 3.1 target of fewer than 70, though significant disparities persist between affluent eastern provinces and remote western regions.

Her technical work also centred on disease elimination and inter-ministerial financing. In 2002, Song contributed to China’s first integrated pilot programme in Henan Province to prevent mother-to-child transmission of HIV, syphilis, and hepatitis B, expanding it to nearly 3000 counties nationwide.

To reduce care delays, she advocated the adoption of rapid diagnostic testing that cut result waiting times from 14 days to 30 minutes – a key operational shift within the comprehensive national prevention package, which official records credit with driving HIV mother-to-child transmission down from 34.8% to 3%.

Song sustained these programmes by embedding maternal health priorities directly into China’s Five-Year Plans, leveraging the State Council’s Working Committee for Women and Children to secure multi-ministerial funding from the Ministry of Finance and the National Development and Reform Commission.

Financial and political weight of an emerging superpower

China emerges as the largest state contributor in mandatory assessed dues to WHO, trailing only three non-state and multilateral donors overall.
China emerges as the largest state contributor in mandatory assessed dues to WHO, trailing only three non-state and multilateral donors overall.

Song’s nomination coincides with a major shift in global health governance following the declared withdrawal of the United States from WHO. Beijing has stepped into this funding landscape with significant financial weight, backed by $320.1 million in projected biennial WHO contributions for 2026-2027. This includes $275.7 million in mandatory assessed dues, making China the largest active state contributor in assessed funding. However, China is not the largest donor overall; it ranks fourth behind non-state and multilateral entities like the Gates Foundation, the European Commission, and the World Bank.

Politically, China secured a seat on the 34-member WHO Executive Board starting in May 2026, positioning Beijing as an insider during the critical screening process in January 2027. Under WHO election procedures, candidates must first clear a 10% threshold of members present and voting to reach a shortlist of up to five. To then be nominated among the up to three candidates submitted to the World Health Assembly, a contender must secure a simple majority of members present and voting on the Executive Board.

This financial and political weight mirrors China’s transition over the past two decades from an international health aid recipient into a major multilateral donor. Song’s personal career trajectory – from directing World Bank-supported rural health initiatives to Belt and Road health cooperation – embodies Beijing’s strategic transformation from domestic capacity-building to projecting global health influence, drawing scrutiny from traditional Western donors.

Geopolitical scrutiny and institutional obstacles

The WHO team arrives in Wuhan in January 2021 - a mission whose unresolved questions form the backdrop of diplomatic scrutiny facing Song’s candidacy.
The WHO team arrives in Wuhan in January 2021 – a mission whose unresolved questions form the backdrop of diplomatic scrutiny facing Song’s candidacy.

Despite her technical credentials, Song’s candidacy encounters formidable diplomatic headwinds rooted in broader Western concerns over China’s expanding political footprint. Global health analysts observe that a Chinese candidate heightens geopolitical friction, drawing strong bipartisan opposition in Washington and rendering potential US re-engagement with WHO far more politically complex. This scrutiny is compounded by residual diplomatic friction over early COVID-19 transparency and persistent US allegations of institutional bias.

Beyond political criticism, WHO’s independent Scientific Advisory Group for the Origins of Novel Pathogens (SAGO) assessed that origin investigations remain inconclusive. SAGO cited missing baseline data, including raw epidemiological files, Wuhan laboratory audit records and staff health logs, and testing data for upstream animal supply farms. While available peer-reviewed evidence favours a natural zoonotic spillover, SAGO stressed that neither the exact transmission pathway nor a research-related incident can be confirmed or eliminated without these withheld records.

In its written response to Health Policy Watch, China’s Permanent Mission in Geneva did not address specific enquiries regarding Song’s strategy for maintaining scientific independence, supporting compliance with the updated International Health Regulations (IHR), or resolving WHO’s budget constraints. Instead, the Mission confined its response to an overview of her administrative track record, noting that further materials would be shared “in due course.”

Furthermore, member states face institutional hesitation regarding executive concentration, noting that China already held the WHO leadership for two consecutive terms under dual Chinese and Canadian citizen Dr Margaret Chan (2007-2017). While Chinese national Qu Dongyu’s second term leading the Food and Agriculture Organization (FAO) concludes in July 2027, his concurrent tenure throughout the 2026-2027 campaign window might reinforce resistance in several capitals against placing a second major UN specialised agency under Chinese executive leadership.

Those reservations have been compounded by controversy surrounding Qu’s leadership style. At a recent FAO assembly in Rome, Qu drew international criticism after warning senior officials that “we’re not allowing you to play the game here of human rights” and insisting that human rights governance belongs strictly in Geneva. The episode has sharpened broader diplomatic anxieties over how Chinese executive leadership manages cross-cutting UN mandates, particularly given Beijing’s tendency to prioritise state-led development over universal human rights frameworks.

A test of technical authority in disruptive times

The 2023 inauguration of Africa CDC’s headquarters in Addis Ababa, financed by Beijing, highlights China’s expanding health diplomacy footprint across the Global South.
The 2023 inauguration of Africa CDC’s headquarters in Addis Ababa, constructed by Beijing, highlights China’s expanding health diplomacy footprint across the Global South.

Song’s candidacy brings a distinctive profile to the race: a physician-scientist and technical administrator whose career centres on primary care equity and South-South health cooperation. For member states seeking a technical reformer aligned with Global South health sovereignty, her domestic record at the National Health Commission offers a concrete template of country-led implementation.

However, her path to Geneva faces steep diplomatic and structural hurdles. To build a winning coalition beyond Beijing’s core voting bloc, Song must convince sceptical capitals of her institutional independence. She must also navigate lingering geopolitical friction over early pandemic transparency, bipartisan opposition in Washington, and member state hesitation regarding Chinese leadership concentration across UN agencies.

Ultimately, her bid forces member states to weigh two competing visions for WHO’s post-US era. One path opts for a senior technical administrator focused on frontline primary care and South-South self-reliance. The other prioritises alternative candidate profiles designed to restore traditional Western donor confidence, and safeguard normative neutrality amid intensifying superpower rivalries.

Note: Health Policy Watch reached out to Song for comments but has not received a response ahead of publication. Profiles will be updated as the campaign progresses, stay tuned on the microsite.

Image Credits: WHO, Shandong University, WHO/HPW, CGTN, African Union.

A patient has his blood pressure tested. People living with diabetes face far higher risk of blood pressure and heart disease.

Over 100 million people in India are estimated to be living with diabetes, and many with the most common form, type 2 diabetes, delay insulin therapy by seven to nine years, according to studies. Dr Viswanathan Mohan, one of India’s leading endocrinologists, explains some of the facts and myths about the condition. 

Health Policy Watch: Why do people in India delay insulin treatment for years, even when it is medically necessary?

Leading Indian endocrinologist Dr V Mohan

Dr V Mohan: It is not just in India. People around the world are reluctant to take insulin because they believe that once they start, they will have to take it for the rest of their lives. In India, people also tend to associate starting insulin with the end of their lives.

They may have seen a patient admitted to an intensive care unit in a critical condition, given insulin and subsequently die. In some cases, the patient may have died from other causes, such as heart failure or multiple organ failure. But people interpret such instances as evidence that starting insulin means the end is near.

In reality, it is quite the opposite. When other medications fail to control blood sugar levels adequately, insulin may be the most appropriate treatment.

Some people also mistakenly believe that insulin is an addictive substance, like narcotic drugs. These are all myths.

HPW: Why do some people believe insulin is addictive, and can patients stop taking it once they start?

Dr V Mohan: This is a myth. Insulin is a life-saving medication, and it is not addictive. A person can stop taking insulin if their clinical condition allows it and their doctor recommends doing so

There is also a view, which I share, that when blood sugar levels are very high in the early stages of diabetes, particularly when someone has been diagnosed late or has gone undiagnosed for a long time, a short course of insulin can have lasting benefits. Even if a patient takes insulin for just one month, with one injection a day for 30 days, the benefits may persist for years in some cases.

HPW: Do all patients with diabetes eventually need insulin?

Dr V Mohan:  It is important to distinguish between the different types of diabetes. In type 1 diabetes, the body produces little or no insulin, making insulin therapy essential for survival. Although type 1 diabetes accounts for a smaller proportion of cases and is often diagnosed in children and young people, adults can develop it too.

This discussion, however, focuses on type 2 diabetes, which accounts for the vast majority of diabetes cases worldwide. Unlike type 1 diabetes, insulin is not necessary for every person with type 2 diabetes. Depending on their individual circumstances, some patients can manage their blood sugar levels through dietary changes, exercise and oral medications.

However, when blood sugar levels remain very high or other treatments fail to provide adequate control, insulin may become necessary.

Doctors sometimes continue adding oral medications even when the additional benefit from each drug becomes progressively smaller. The first medication might reduce a patient’s HbA1c level, a measure of average blood sugar, by two percentage points. A second drug might bring a further reduction of one percentage point, while a third might lower it by only 0.3 or 0.4 percentage points. The benefit may diminish further as additional drugs are introduced.

At that stage, doctors may recommend insulin to bring blood sugar levels under control. But patients can remain reluctant, viewing insulin as a last resort rather than a necessary step in managing their condition.

‘This is the time when we recommend insulin, but people resist, saying that insulin is the last thing they would want to take,’ Mohan says.

HPW: Have newer treatments changed this situation? And has the World Health Organization’s Global Diabetes Compact improved access to care?

Dr V Mohan: We now have newer drugs, including GLP-1 medicines, which have been available in India for the past year or two. When two or three oral therapies fail, doctors may prefer these drugs before insulin. However, they have their own constraints, particularly their high cost.

As far as the WHO Global Diabetes Compact is concerned, it has helped raise awareness about the rights of people with diabetes. One of its aims was that no adult or child with type 1 diabetes should die because of a lack of insulin. Insulin was recognised as a fundamental necessity, and global benchmarks were established.

However, whether these commitments have translated into measurable improvements in the quality of care is not something I can point to a formal study on. Awareness has certainly increased.

insulin pens in egypt
Insulin pens have made it easier for people with diabetes to administer the drug themselves.

HPW: Does insulin have any side effects?

Dr V Mohan: Insulin is a miracle drug because it can reduce blood sugar levels in people with diabetes. But it has some side effects. One is weight gain, because insulin is a hormone. Another is hypoglycaemia, or low blood sugar, which patients need to be aware of and know how to manage.

HPW: With GLP-1 drugs now available, can patients avoid insulin altogether?

Dr V Mohan: Certainly not. In complicated situations, insulin remains essential. For example, it is used in the management of blood sugar during surgery and in certain acute medical situations, including heart attacks and strokes. During the COVID-19 pandemic, insulin was also used to manage blood sugar levels in patients who needed it. Newer medicines do not mean insulin is no longer necessary. The appropriate treatment depends on the patient’s condition.

HPW: Clinical inertia has also been identified as a reason for the seven-to-nine-year delay in insulin treatment. What role do doctors play?

Dr V Mohan: It is not only patients who are responsible for these delays. Doctors can also contribute to them. Prescribing a tablet is relatively simple: a doctor can tell a patient to take it in the morning or afternoon, before or after a meal. Insulin requires much more instruction and time.

Doctors must teach patients how to inject insulin, where to inject it, how deep the injection should go and how to rotate injection sites. They must also explain how to recognise and manage low blood sugar and how to monitor glucose levels themselves.

All this takes considerable time. A doctor may think they will explain everything at the patient’s next visit. But the patient may not return for months or even a year, sometimes because they fear being advised to start insulin. The delay continues, and this clinical inertia can persist for years.

Meanwhile, patients may develop complications affecting their eyes, heart and kidneys because their blood sugar levels remain above recommended targets.

HPW: Why do some patients continue to have uncontrolled blood sugar levels even after starting insulin?

Dr V Mohan: There can be several reasons. Some patients may become less careful about their diet or sleep because they believe that starting insulin means their diabetes is now under control. Stress can also affect blood sugar levels.

Dosage is another factor. Insulin doses need to be adjusted according to blood sugar monitoring. If patients do not monitor their levels properly, their blood sugar may remain uncontrolled.

Taking insulin is not enough on its own. Patients need appropriate doses, regular monitoring and follow-up care.

HPW: If you could change one thing about India’s healthcare system to improve diabetes care, what would it be?

Dr V Mohan: I would focus on precision diabetes treatment. We now know that not everyone has the same type of diabetes. Some people have type 1, others have type 2, and there are additional forms of the disease.

First, patients need an accurate diagnosis of the type of diabetes they have. Second, the diagnosis must be made early, rather than allowing people to go years without knowing they have the disease.

Third, patients must receive the appropriate treatment, whether oral medicines, insulin or GLP-1 drugs, depending on which treatment is best for them.

Most importantly, there must be regular follow-up. Some people ask why they should attend check-ups when they have no symptoms. This is one of the biggest mistakes they can make. Diabetes is called a silent killer, and the absence of symptoms does not mean that blood sugar levels are under control or that complications are not developing.

Dr V Mohan is an Indian physician specialising in diabetology. He chairs Dr Mohan’s Diabetes Specialities Centre, a hospital chain headquartered in Chennai, designated as a WHO collaboration centre on NCDs. He also chairs the Madras Diabetes Research Foundation (MDRF). He has authored over 1,200 research publications and has been ranked among the world’s top 2% of scientists by Stanford University.

 

Image Credits: WHO/A. Loke, S. Samantaroy/HPW.

The WHO headquarters in Geneva, Switzerland.

 The World Health Assembly (WHA) will choose WHO’s ninth Director-General next May without having defined the job. Part I of this analysis sought to learn from the experiences of eight previous incumbents. Part II goes back to the WHO constitution, takes stock of the world’s health and that of the organization safeguarding it, before asking what its next chief must actually do.

Any employer who advertised a post with a person specification but no job description would be laughed out of the recruitment business. And yet, that is what the World Health Assembly does.

Its nine criteria for Director-General ask for a strong health technical background with international experience, leadership and communication skills, management competence, cultural, social, and political sensitivity, alongside commitment to WHO, good health and a working language.

These are all good requirements that every one of the eight predecessors assessed at Part I satisfied. But, as subsequent history showed, this did not predict or differentiate between their eventual – wildly varying – performances.  

Post without a job description

The problem arises from the Delphic nature of the original constitutional designation of the Director-General as the organization’s “chief technical and administrative officer” without indicating what that means. It led to 78 years of rule-making that produced copious documentation on the election process without specifying the incumbent’s actual duties.

In fact, it is worse than that. Successive WHA resolutions have loosened specificities. For example, DG criteria revision in 2012 dropped the 1996 requirement for “proven historical evidence for public health leadership” while adding subjective “behavioural” tests.

The supposed reason was to give polarised electors greater political flexibility. There is nothing inherently wrong with that as global health is ultimately a political enterprise. But objective specifications could distinguish good from bad politics in a science-driven enterprise.

But that is not the case with WHO and creates a core accountability problem. If you don’t know what you want your chief officer to do, how do you select them or design the metrics to assess their delivery?

Leadership traps

This generates conflicts of interest for politically elected DGs. Because allowing them to define their own job and mark their own homework by their own yardsticks tempts them to bend organizational strategies. And it leaves disappointed electors progressively critical of the DG they had endorsed with great fanfare.

Nowadays, DG candidates publish policy manifestos on elaborate websites, and electors can see what they would get. But the reality is that once a DG election is concluded and the champagne is popped, the winner’s website and glitzy messaging are consigned to oblivion. No one follows up on whether the winner sticks to what they said they would do.

Unsurprising, therefore, that all previous DGs who wanted it got second terms despite shortcomings evident in their first term. International agency governance is naturally conservative and veers towards the principle of the devil-you-know being safer.

Deeper confusion comes from conflating WHO’s persona and purpose as a permanent body with that of its Director-General, who is a temporary custodian. It exalts an incumbent’s status towards that of an old-fashioned head of state tending towards a sense of entitlement and impunity.

To be fair, this does not always come from a leader’s character. When I talk privately with present and past heads of agencies, they profess discomfort with the trappings of office, forced upon them by their courtiers. But obviously, they choose the people that surround them, the culture they create, and they are human enough to enjoy the privileges they bask in. 

I have also observed during tracking performance over long tenures how the “centeredness” of leaders shifts with the accumulation of fatigue, errors, arrogance, crises, bad advice, and enemies. Perhaps that explains the adage, “All political lives…end in failure … because that is the nature of politics and human affairs”.

The trappings of the office of the Director-General are akin to those of a head of state.

Challenges for defining the DG’s job

There are, therefore, compelling reasons why the global public interest demands guardrails to be constructed around the WHO DG’s position through a formal job description.

However, this challenges member state electors at the WHA. How can they write the DG’s job description if they are not clear on what they want done? To be sure, their desires are expressed in over 3,200 resolutions since 1948. And as the assembly understood that passing more resolutions is untenable for the financially strapped organization, it switched to supposedly less fiscally demanding “decisions”, with over 1,000 in existence. 

By a conservative count, the WHA’s resolutions and decisions run to more than 1.5 million words. This is twice the length of the Bible and, like in scripture, revocations are sacrilegious although there is now a process to weed out dead WHO resolutions. No wonder linguistic fluency is a critical DG criterion.

However, even the most dedicated study of WHO’s holy words can’t answer the question of what a very human DG should be reasonably asked to do over their limited tenure. Partly because the high priests of WHA doing the anointing come from differing sects. 

This begs the obvious question: when the candidates appear at the temple – two physical forums and an electronic web forum – how will their proffered dogmas be evaluated? Beyond relying on gut instincts and the whisperings of favoured global health pundits?

This column seeks to construct a formal job description for the next WHO DG, which requires reverting to undisputed fundamentals. Article 1 of its constitution says that the WHO objective of “the attainment by all peoples of the highest possible level of health” is to be realised through 22 functions set out at Article 2 with an extraordinary prescience that remain as fresh today as in 1946.

Following that organizational compass can help the DG avoid getting lost in the treacherous jungles and swamps of global health. However, the constitution is the organization’s framework and not the chief’s marching orders. Devising that job description takes authorisation from the last line of Article 2 for “all necessary action to attain the objective of the organization”.

So, what necessary actions are personally required from the next DG over their initial tenure in 2027-2032? They derive from the prevailing state of global health and WHO’s legitimate role.

The state of the world’s health

Non-communicable diseases are taking their toll across the world.

At a time when global institutions suffer intense – and often unfair – criticism, they have become adept at spinning trends in their sectors to show that they are not idle and remain investment-worthy. 

Unfortunately, that also applies to normative guardians such as WHO, whose public messaging can verge on self-promotion. This makes balanced assessments of complex trends harder, as even authoritative Global Health Estimates can be spun to suit political or funding aims.

The excessive optimism and delusional beliefs that follow are always a great risk for leaders, and the next DG would be prudent to take a glass-half-empty perspective on the state of world health. With that caveat, what are the most strategic global health trends in the new DG’s in-tray?

Living longer, feeling worse

The new DG inherits a world that is living longer but lagging in healthy life expectancy. Non-communicable diseases now cause 74% of deaths and the fastest-growing burdens are diabetes, dementia, mental ill-health and drug use. That is this era’s first fact: the world’s dominant health problems are chronic, behavioural and expensive, while WHO was originally built to fight infections. Institutional DNA will always be more difficult to edit.

Disappointed hopes

The second fact is that promised progress has stalled. The service coverage index for universal health coverage has barely crept up from 68 to 71 between 2015 and 2023. A quarter of humanity faces financial hardship from out-of-pocket healthcare payments, while 1.6 billion people were marooned or pushed deeper into poverty in 2022. Meanwhile, a shortfall of 11.1 million health workers is forecast by 2030.

While maternal deaths dropped 40% since 2000 and child deaths halved, these were not fast enough. Without course changes, the world will forgo the chance to prevent 700,000 maternal and eight million under-five deaths before 2030. Vaccine confidence and routine vaccinations have declined, illustrated by the 11 million people who needlessly acquired measles in 2024.

The next DG must get their script ready for confessing in 2030 that the Sustainable Development Goal for health have been missed. But more importantly, what will they propose to succeed it?

Old adversaries returning

The third fact is the return of old challenges. Cholera, a disease of broken water systems and broken states, killed more than 7,800 people last year. With seven conflict-affected countries accounting for nine deaths in 10, this is the highest annual incidence since 1999. 

Malaria incidence is also rising again, and tuberculosis remains the world’s leading infectious killer. The uncontrolled Bundibugyo Ebola outbreak that originated in the Democratic Republic of Congo (DRC) is setting new records. Antimicrobial resistance is the pandemic that smoulders on. 

The next pandemic is a matter of when, even as considerable energy is expended in signing watered-down pandemic agreements and making non-binding political declarations that cannot be implemented because a vital pathogen access and benefit-sharing (PABS) annex remains un-agreed.

Climate is changing health futures

Marcela and her baby under a mosquito net. Her home in Mozambique was destroyed by floods earlier this year, and two of her children contracted malaria while in a shelter.​ Climate change is increasing malaria.

The fourth fact is that climate change has become a health determinant in its own right with associated risks at their worst levels on 13 of 20 indicators. Excessive heat kills an average of 546,000 people annually, up 23% since the 1990s. That is apart from other indirect health impacts (such as disasters and pollution) that WHO has not yet fully categorised and begun tracking rigorously, rather than relying on modelled estimates. 

But many diseases are rising with the thermometer. For example, dengue’s transmission potential has risen by nearly half since the 1950s, malaria is climbing into highlands that were once too cold for it, and many non-communicable and reproductive health conditions are riskier. Health ministries are noisy participants at climate summits but rarely get to write more than a paragraph in communiques.

Health as a target

The fifth fact is that health itself is in the crosshairs. WHO’s recorded 1,283 attacks on healthcare, mostly in places such as Gaza, Sudan, and Ukraine. This is certainly an underestimate, with the dismantling of overwhelmed health systems in conflicts and crises affecting the survival of millions of people. 

The Geneva Conventions’ oldest protection, the inviolability of the wounded and those who treat them, is being repealed through impunity. There is plenty of advocacy but specific strategies to maintain healthcare in hostile contexts are not clear.

Facts under fire

WHO Western Pacific Regional Director Dr Saia Ma’u Piukala and WHO Director-General Dr Tedros Adhanom Ghebreyesus at the 77th committee meeting for the Western Pacific.

The sixth fact is that the facts themselves are contested. Vaccine scepticism is only the most visible symptom of a wider disorder that needs differentiated responses. Starting with misinformation from honest error that is sincerely shared such as the parent who reads that measles is mild. That is distinct from malinformation: facts deployed to deceive, as when a real but rare vaccine side-effect is presented without the far larger risk of the disease it prevents. And disinformation or falsehoods manufactured purposefully like casting the Pandemic Agreement as surrendering national sovereignty. 

Then there is creating doubt for profit by industries whose products can kill, such as tobacco, sugar, or fossil fuels, by funding research designed to muddy scientific waters. 

Further genres include influencer medicine that reaches more people than health ministries to promote, for example, bizarre “cures” for autism, and the lucrative wellness economy. Arriving at scale too is synthetic content generated by machines that overwhelm our capacity to counter them. But most sinister is the new official misinformation from once-trusted institutions, as with the US Health Department directing the revision of childhood vaccination protocols.

Underneath all lies the oldest contest: over numbers themselves. WHO’s own estimate of 22.1 million excess deaths from the pandemic is three times the official count. The death tolls of Gaza and Sudan are argued over as political ammunition. Meanwhile, only a fifth of the world’s deaths are recorded with a meaningful cause.

Whose job is it to do the counting? By default, governments, but when they don’t, won’t or can’t, or they deliberately miscount, what is WHO’s role? The organization’s normative authority – its only asset that money should not buy – is attacked daily by governments, platforms and a medical counter-culture with a global reach. Defending it, simply through slicker communications, is inadequate.

Evaporating resources

The seventh fact is money. Development assistance for health fell 21% in 2025, from $49.6 billion to $39.1 billion, its lowest since 2009, driven by American and other donor cuts. Sub-Saharan Africa lost a quarter of its support, and forecasters expect the decline to continue to 2030. One modelling study puts the cost of unreplaced US withdrawal at 4.1 million additional AIDS deaths, 607,000 tuberculosis deaths and 2.5 million child deaths by 2030.

The aid-financed architecture and disease partnerships of the past quarter-century, such as Global Fund, Gavi and US President’s Emergency Plan for AIDS Relief (PEPFAR), are also contracting, and are being replaced by a web of bilateral compacts that leverage trade, economic, or security deals that bypass Geneva altogether.

Dr Tedros meets with Minister of Health of Germany Nina Warken in May. Germany remains one of the largest donors to the WHO.
Dr Tedros meets with the Minister of Health of Germany, Nina Warken, in May. Germany is one of the largest donors to the WHO.

The state of WHO

If the world’s health is the demand side of the DG’s job description, the organization itself is the supply side. Health being the responsibility of states, the test for WHO is not whether it solves the above problems which, in any case, no international body can do on its own.

The real measure of the organization’s worth is around how well it helps states through discharging its 22 Constitutional functions, five of which carry the most significant weight:

Directing and coordinating authority

Ambassador Anne-Claire Amprou and WHO Director-General Dr Tedros at the conclusion of the pandemic agreement talks.

Article 2(a) makes WHO “the directing and co-ordinating authority on international health work”. But the organization is no longer fully empowered to do that since financial influence and operational muscle sit increasingly with others such as the Global Fund, Gavi, Gates Foundation and US-directed bilateral compacts. 

The WHO retains its unique authority to convene 193 states, but only if they co-operate. That delivered the landmark tobacco treaty, International Health Regulations and, however incomplete, the Pandemic Agreement.  WHO’s real authority – now only moral and procedural – is much weakened, but it is the one asset rivals cannot replicate. 

Therefore, the next DG will need to be a highly morally respected figure but that will not be enough in the context of global cynicism and fragmentation.  They must also forge a new strategic path for convening and coordinating a system that WHO no longer commands.

Norms, standards and rules

Articles 2(k), (s), (t) and (u) — conventions, nomenclatures, diagnostic standards, and standards for medicines and biologicals — are where WHO does its constitutional job best and most invisibly. The International Classification of Diseases, the Essential Medicines List, the pre-qualification of vaccines and drugs that every procurement agency relies on, and the amended International Health Regulations in force since September 2025, are examples of the global health system’s operating code.

They were written by staff whose numbers have been drastically slashed, with mid-level professionals who do most of the technical work bearing the brunt. The paradox for the new chief is that the function with the highest return is the one donors least like to fund, because nobody cuts a ribbon on a nomenclature. It is also the function under the sharpest political attack, as with all norm-setters in today’s world.

Therefore, the next DG should optimise WHO’s norm-setting business by reversing the traditional top-down approach and restricting standard-setting to the most critical areas for collective health. 

Not every medical product or activity has to be normatised and regulated at a global level, and nations must learn to set more of their own specifications in their own contexts, with WHO available, if countries invite and pay for it, to facilitate evaluation, lesson-learning, and experience exchange among nations.  

Emergency action

WHO's Dr Roseline Belzaire (centre) and Africa CDC's Dr Yap Boum on the ground in Ituri in the DRC to address Ebola.
WHO’s Dr Roseline Belzaire (centre) and Africa CDC’s Dr Yap Boum (right) in Ituri in the DRC to address Ebola.

Article 2(d) asks WHO to furnish “necessary aid in emergencies” at a government’s request, and 2(g) to eradicate epidemic disease. After West Africa’s Ebola outbreak, member states forced the building of an operational arm, and it has worked harder than its critics allow: some 500 threats verified and 450 responded to last year, and the Bundibugyo emergency was declared within two days. 

But declaring is much cheaper than responding. The organization’s emergency funding depends on a contingency fund it must refill by appeal, its field logistics on partners, and its surveillance on country systems that aid cuts have gutted. This is partly why the fastest public health emergency declaration in WHO’s history has not been rewarded by speedy control of the second-largest Ebola epidemic. 

The next DG must acknowledge the brutal lesson that, regardless of what the organization does, it will always be blamed for being too slow or late by virtue of the epidemiology of lethality and rapid spreadability of new organisms amidst a changing physical and environmental context. 

This requires a radical revision – not continuous expansion – of WHO’s emergency operational capabilities as these will never keep up with demands. Probably that means restricting WHO to upstream roles and leaving operations to regional organisations and national capacities. 

The next DG’s task, therefore, is to develop and gain a new consensus among member states on what they can realistically expect WHO to do.

Support to countries

A delegate at the 73rd session of the WHO Regional Committee for the Eastern Mediterranean in Cairo, Egypt, in October 2026

Article 2(c) and (e) of the constitution – strengthening health services and providing technical assistance – is where WHO claims many of its “results”, through more than 150 country offices. It is also where the organization is thinnest, most dependent on earmarked donor money, and most exposed to the regional structure that Article 44 onward creates. 

The six regional directors are elected by their own constituencies that the Director-General can neither appoint nor remove, but their performance or misconduct bears directly on the DG’s own reputation.

There is much ambivalence about this structure, with its inherent tensions polarising and paralysing the organization and its stakeholders at critical moments. The next DG should decisively end this by formally embracing Mahler’s lament of WHO as an “association of regional offices”. Not least because geopolitical winds will blow ever more forcefully towards the primacy of regions and nations. Country support is also the constitutional function the assembly talks most about, and the next chief must honour that. 

The WHO as an institution

The constitution assumes a secretariat that is solvent, trusted and accountable. But it is criticised on all three counts. The organization has also lost a founding member for the first time in its history, with a second giving notice.

The earlier Congo jobs-for-sex scandal, profligate travel revelations and two regional director removals have each cost trust. Despite strident declarations of ‘zero tolerance’, it is currently falling behind its resolve to clean up the house.

There are complex – and not necessarily interconnected – reasons for these failures. But a core aspect is funding. WHO’s base budget has fallen from $5.3 billion to $4.2 billion. Progress has been made to increase assessed contributions to cover 40% of the budget. The remainder is voluntary and earmarked, so whoever pays still decides. The senior ranks nearly doubled in the fat years and have been trimmed in the thin ones, with more juniors going first.

The next DG’s priority must be to place the organization’s funding on the rational basis of democratic accountability. That translates into all core WHO tasks being conducted within the base budget composed of the total of regular assessed contributions of member states. It implies reducing the extent of those tasks if members agree on an insufficient budget level.

All core tasks do not have to be discharged from Geneva, and some global core tasks could also be conducted from regional offices. The associated principle could be that no more than, say, 20% of the base budget is spent at Geneva headquarters, with the rest allocated to regional offices. 

Additional voluntary contributions from donors for their own favoured programmes should, over time, be done away with. Those who wish to provide more funding for global health can find other channels such as directly to countries or via other agencies. WHO should not be a subcontractor to donors.

The DG who manages to design and deliver a new sustainable and robust funding contract informed by consistent new principles will leave a profound mark on the organization.

Towards the Director-General’s job description

A child born in the same year as WHO expected to live, on global average, just 46 years. A child born today can expect to live 27 years longer. Measured against Article 1 of its constitution, the organization can claim a significant share of the credit for enabling the largest improvement in human health in history.

But when measured against Article 2’s practical functions, the verdict is nuanced. Against the many changes spanning decades, to the determinants of health, WHO is labouring harder and harder to achieve less and less. 

Since WHO began measuring healthy life expectancy in 2000, the world has added six and a half years of life but under five years of health. In short, the gap between living and living well has widened to 10 and a half years. Of course, that is not the sole responsibility of WHO and less even of its DG.

Nevertheless, an organization originally built to add years to life must shift to add life to years. But this is far more complex. Not least because we cannot say how many years of health climate change, chronic diseases, mental illness, or wars are taking, because measurements of healthy life are modelled rather than counted.

Meanwhile, in institutional terms, WHO appears strongest where it is least seen and weakest where it is most expected.  That creates the perception imbalance that so bedevils confidence in the organization and inevitably reflects badly upon its leaders.

The new DG will want to rise above that after taking a hard look in the organisational mirror. That has been the purpose of this piece, which also suggests pointers for what is required from future WHO leadership. But this is still too imprecise a basis for electing the ninth DG. That requires a specific job description against which electors can quiz candidates to determine their fitness for the position.  

We will get there at Part III of this series. 

Mukesh Kapila is professor emeritus of global health and humanitarian affairs at the University of Manchester, and a board member of Health Policy Watch. Vital Signs in Global Health is a regular column, and the opinions expressed are solely those of the author. 

Image Credits: WHO, WHO EMRO, NCD Alliance, Global Fund, ohn Kelly Halina/ WHO, WHO/Christopher Black.

Who will steer the World Health Organization through its next chapter? Explore Health Policy Watch’s daily series examining the platforms, records, and institutional hurdles facing each contender for WHO Director-General, continuing today with Budi Gunadi Sadikin. Access all candidate profiles on our dedicated election site.

Turnaround proposition: Sadikin’s campaign tests whether Member States will elect a corporate balance sheet expert to lead WHO through severe financial distress.
Turnaround proposition: Sadikin’s campaign tests whether member states will elect a corporate balance sheet expert to lead WHO through severe financial distress.

Indonesia’s nomination of its Health Minister, Budi Gunadi Sadikin, for Director-General of the World Health Organization (WHO) introduces an unconventional candidate to the race for the 2027-2032 term. Entering a field alongside medically credentialed contenders, Sadikin stands out as the sole nominee whose career originated outside clinical medicine and epidemiology.

With the publication of his official election platform, “Healthy Long Lives for All”, he has anchored his candidacy in a structured campaign framework encapsulated by his initials: Build, Grow, Scale (BGS). Positioned around economic reform, health sovereignty, institutional efficiency, and the principles of the Accra Reset, his campaign unfolds as the agency is managing severe financial distress and workforce reductions.

Representing the world’s fourth-most populous nation, Sadikin brings a distinct Global South perspective grounded in the frontline health realities of a complex middle-income country. However, his central challenge will be convincing member states that an outsider and financial reformer can safeguard WHO’s scientific integrity and technical authority, while demonstrating that top-down executive experience can build multilateral consensus across a diplomatically fragmented global health landscape.

Strategic vision: economic reform and health sovereignty

Sadikin’s platform calls for localized biomanufacturing and regional production capacity across 30 to 50 Global South nations.
In line with the Accra Reset proposals, Sadikin’s platform calls for local biomanufacturing and regional production capacity across 30 to 50 Global South nations.

Sadikin’s platform grounds global health reform in country-led agency, fiscal realism, and institutional focus. At the first public candidate exchange during the World Health Summit in Berlin, he expanded on his core thesis arguing that WHO must return to its constitutional roots to restore multilateral trust across three core pillars:

  1. Build strong national health systems: Grounded in domestic reform, he advocates for country-led national health plans. Drawing on his banking background, he targets the communication gap between health and finance ministries, helping health leaders translate technical priorities into credible financial plans that finance ministers, development banks, and donors can fund.
  2. Grow regional resilience: Rejecting donor-dependent charity in favour of health sovereignty, Sadikin advocates establishing end-to-end vaccine and diagnostic manufacturing capacity across at least 30 to 50 nations in the Global South.
  3. Scale Global Impact: His platform argues that rather than attempting to fund every health need from its restricted balance sheet, WHO must leverage external capital and align global health entities behind single national health strategies.

Complementing these three pillars is a sharp critique of WHO’s overextended scope. Citing consultations with nearly 100 health ministers worldwide, Sadikin argued in Berlin that WHO currently “does too many things” and must return strictly to its two core constitutional functions: setting evidence-based scientific norms and standards, and exercising its unique convening power. To reduce administrative overhead, he advocates systematically scaling back operational and implementation functions that external partners or country offices can perform more efficiently.

Addressing WHO’s budget constraints and heavy reliance on earmarked voluntary contributions, he frames donor earmarking as a direct symptom of institutional distrust. Drawing on his role as co-chair of the high-level panel on the Accra Reset, he advocates for costed, one-stop country compacts that streamline global assistance to restore financial trust and eliminate multi-agency duplication across WHO, Gavi, and the Global Fund. “As a country … it is ridiculous and becomes more complex when I have to deal with three separate institutions on malaria, each with their own earmarks,” he stressed in an interview with Health Policy Watch.

To measure long-term success, Sadikin set a clear operational benchmark in Berlin: creating a re-unified, trusted WHO where all member states willingly pay their assessed contributions because they proudly recognise the agency’s direct role in enabling their populations to live long, healthy lives.

From corporate banking to pandemic management

Sadikin’s transition from commercial banking CEO to health minister underpins his campaign focus on capital mobilization and balance sheet restructuring.
Sadikin’s transition from commercial banking CEO to health minister underpins his campaign focus on capital mobilisation and balance sheet restructuring.

His focus on capital mobilisation and fiscal discipline flows directly from Sadikin’s 30-year corporate background prior to public service. A nuclear physicist by training (Institute of Technology Bandung, 1988), he rose through commercial banking to become CEO of PT Bank Mandiri Tbk, managing over $65 billion in assets. Drawing on his background leading major corporate restructurings, Sadikin served as president director of state-owned mining firm Inalum, where he led negotiations and financing for the US$3.85 billion acquisition of a majority stake in PT Freeport Indonesia.

Applying his financial expertise to public health administration, Sadikin points to this track record, leveraging centralised bulk procurement to save $553 million on advanced medical devices and achieving a 32% price reduction across selected essential medicines and consumables.

When COVID-19 struck, Jakarta tapped his corporate logistics background. Appointed health minister in December 2020, he applied supply-chain tactics to direct the rollout of 453 million vaccine doses across 6,000 inhabited islands.

Turning emergency logistics into permanent structural reform, he expanded routine childhood immunisation pipelines with PCV, HPV, and rotavirus vaccines, driving Indonesia’s global rank for zero-dose children down from 3rd to 7th. This shift toward preventive primary care yielded measurable national health outcomes, with Indonesia’s childhood stunting prevalence falling from 24.4% in 2021 to 19.8% in 2024, according to national health data.

Despite pushback over an executive-style overhaul of a health law that centralised medical licencing and specialist oversight directly under ministry control, his domestic record propelled his entry into global health diplomacy. Co-leading the 2022 G20 health track, he spearheaded the creation of the World Bank-hosted Pandemic Fund.

Aside from co-chairing the high-level expert panel on the Accra Reset, Sadikin holds board seats at Gavi and the Stop TB Partnership.

Voting bloc dynamics and geopolitical mediation

WHO Director-General Dr Tedros Adhanom Ghebreyesus met with Sadikin at WHO headquarters in July 2026.
WHO Director-General Dr Tedros Adhanom Ghebreyesus met with Sadikin at WHO headquarters in July 2026.

To demonstrate multilateral commitment ahead of his campaign, Jakarta backed its candidate with direct capital, scaling up its recorded WHO portal contributions nearly fourfold from $7.67 million in 2024-2025 to $29.39 million for the 2026-2027 cycle. This baseline – which features $13.13 million in flexible thematic funding – was further augmented by President Prabowo Subianto’s pledge of an additional $30 million to the WHO investment round within weeks of Sadikin’s nomination.

Reinforcing Sadikin’s broader diplomatic strategy, this financial backing leverages Indonesia’s weight as an ASEAN leader, a G20 economy, and a founding Non-Aligned Movement member to build cross-regional consensus. Translating that non-aligned posture into active campaign momentum, Sadikin has logged 16 bilateral meetings with a diverse coalition spanning Brazil, Egypt, France, India, Mexico, the UAE, and the US. He subsequently expanded his Americas outreach at PAHO’s 63rd Directing Council in Washington, D.C., building direct ties with Small Island Developing States.

This non-aligned positioning allows him to bridge diverging Global South priorities with competing global powers like China and the United States.

Addressing US re-engagement in an interview with Health Policy Watch, Sadikin framed global health security as an inescapable, non-political bridge: “It is like a family living in the same house called Planet Earth with eight billion people,” he noted. “Scientifically, it is impossible for the US to insulate itself from pathogens … Stroke, heart attacks, and cancer affect an American, a European, an African, or an Indonesian equally. Health is the ultimate commonality we can use as a key argument to work together.”

Policy frictions, environmental realities, and normative limits

Agricultural deforestation and plastic waste pollution test how low and middle income countries align national industrial interests with environmental health mandates.
Agricultural deforestation and plastic waste pollution test how low- and middle-income countries align national industrial interests with environmental health mandates.

However, on the campaign trail, Sadikin must navigate diplomatic scrutiny over how his home country’s domestic record aligns with WHO’s normative mandates across three key areas. Indonesia’s conservative legal framework, which criminalises extra-marital sex and cohabitation under its revised penal code, restricts abortion access, and does not recognise same-sex unions, creates immediate political friction with liberal member states advocating SRHR protections.

Speaking with Health Policy Watch, Sadikin addresses this tension by separating global technical standards from domestic execution. While WHO must operate as an unbiased, science-based normative body, setting standards to prevent maternal mortality, unintended pregnancies, and sexual violence, actual delivery “must remain within the national law and policy of each member state,” he maintains.

Additionally, his recent offhand public remarks – such as describing obesity as “a problem that mainly happens in developed countries” during a Reuters interview – drew criticism for conflicting with WHO’s global non-communicable diseases (NCD) targets and rising obesity rates in middle-income nations. Responding to this scrutiny, Sadikin clarified that national population screening data show undernutrition predominated in primary schools (6-12), while overnutrition officially surpasses undernutrition in high school and upper-middle-income cohorts.

Finally, reflecting a key structural gap in his portfolio, his public record shows a lack of documented climate-health initiatives, dedicated financing instruments, or heat-protection policies. Indonesia’s standing as the world’s largest palm oil producer and a major contributor to plastic waste burning and microplastic pollution presents a complex backdrop for a candidate leading global environmental and planetary health initiatives.

Acknowledging these environmental burdens candidly, Sadikin framed his domestic role pragmatically: “As Health Minister, my job is to fix the downstream side at the end of the tunnel,” noting that curbing air, water, and sanitation risks requires complex inter-ministerial coordination across a vast middle-income nation.

A balance sheet expert for disruptive times?

Navigating domestic normative frictions and his non-clinical background will test his diplomatic agility. While liberal member states are likely to scrutinise Indonesia’s conservative SRHR stance and his portfolio’s climate gaps, many capitals may view these issues as secondary to his core assets: proven financial pragmatism, supply-chain execution, and capital mobilisation.

Ultimately, member states must decide whether private-sector financial discipline and balance-sheet restructuring offer the right antidote for an agency in severe fiscal crisis – or whether an outsider can sufficiently safeguard WHO’s normative and scientific authority.

Note: This article incorporates research findings and comparative evaluations from Rifat Hossain. Profiles will be updated as the campaign progresses, stay tuned on the microsite.

Image Credits: WHO, Chuanchai Pundej via Canva, Creativa Images via Canva, Naya Nurindra via Canva.

Panellists (left to right): Akila Kosaraju, Chikwe Ihekweazu, Jane Halton, Paul Friedrichs, David Reddy, and moderator Shiulie Ghosh speaking during a World Health Summit panel on global health security and biodefence.
Panellists (left to right): Akila Kosaraju, Chikwe Ihekweazu, Jane Halton, Paul Friedrichs, David Reddy, and moderator Shiulie Ghosh.

Speaking at a flagship World Health Summit panel global health officials and pharmaceutical executives urged governments to reframe pandemic preparedness as ‘biodefence’ – a core national security asset and not a discretionary health expenditure.

BERLIN – That strategic pivot is becoming urgent as both global health and aid budgets shrink and multilateral diplomacy on pandemic prevention, preparedness and response stalls.

The Pandemic Agreement is in a gridlock with member states still at odds over the details of a  Pathogen Access and Benefit-Sharing (PABS) system – the contentious annex governing the sharing of biological samples and sequence data that must be concluded before the broader WHO Pandemic Agreement can be ratified by member states and come into force.

Chikwe Ihekweazu urges agreement on WHO PABS.
Chikwe Ihekweazu urges agreement on WHO PABS.

“By May 2027, we need countries to come together and agree the PABS to the pandemic agreement,” urged Chikwe Ihekweazu, executive director of the WHO Health Emergencies Programme during the panel discussion, co-hosted by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA),  “Otherwise, our generation will live in regret.”

His warning comes amid accelerating health security risks – ranging from the active Ebola epidemic in the Democratic Republic of the Congo and a recent hantavirus outbreak aboard a vessel carrying crew members from 23 nations off Cape Verde to ‘dual use’ threats from military research or use of artificial intelligence by hostile actors to generate dangerous new pathogens.

Compounding threats drive health security risks

Members of the West Virginia National Guard’s Task Force Chemical, Biological, Radiological and Nuclear (CBRN) Response Enterprise assist medical responders to COVID-19 patients of a West Virginia nursing home in Apri, 2020.

Currently, however, the spillover of zoonotic diseases into human populations remains the primary catalyst for disease outbreaks, as environmental damage, climate pressures, and habitat destruction accelerate pathogen transmission between animals and humans. Resurgences in active conflict zones, such as in eastern DRC, demonstrate how transmission of such pathogens can quickly overwhelm fragile health infrastructure.

Reinforcing the urgency for better health security measures, David Reddy, director general of IFPMA, cautioned governments against ignoring long-term biological risks while focusing on immediate geopolitical crises.

“The next pandemic may not be the closest snake, but it might be the biggest, meanest snake we’ve ever seen, and it is worth considering where that might be hiding and doing something about it,” Reddy said.

Simultaneously, antimicrobial resistance (AMR) poses a silent, increasing threat that risks eclipsing the mortality of acute pandemic outbreaks.

“It’s estimated that the number of deaths between 2025 and 2050, if we aren’t able to address antimicrobial resistance, could be in the order of 39 million people, which is just extraordinary and outstrips pandemics,” Reddy added.

AI’s double-edged sword

Akila Kosaraju highlights AI-driven novel antibiotic discovery.
Akila Kosaraju, CEO of Phare Bio, highlights AI-driven novel antibiotic discovery.

Technological innovation is helping to overcome traditional market failures in antibiotics manufacturing. With generative models screening chemical space 10,000 times faster than traditional laboratories, artificial intelligence is transforming R&D for novel antibiotic compounds to counter AMR.

“Within three days, AI was able to come up with a solution that our medicinal chemists were equal parts amazed and troubled by,” said Akila Kosaraju, CEO and co-founder of Phare Bio, at the panel, sparking laughter and surprise among the audience.

At the same time, experts warned that AI models lower technical barriers by substituting for decades of tacit laboratory experience. Open-source genome models enable non-expert actors to computationally design novel viral sequences and optimize pathogens for higher transmissibility, lethality, or immune evasion.

These technological threats compound the potential risks of pathogen escape from the growing number of high-containment Biosafety Level 4 (BSL-4) laboratories, three-quarters of which are located in densely populated urban centres, according to analyses by the RAND Corporation, a global health security think tank.

Economic case for proactive ‘biodefence’

David Reddy warns against ignoring long-term risks.
David Reddy warns against ignoring long-term risks.

Despite technological advances, security against expanding biosecurity risks remains imperative and requires framing as a strategic investment rather than a discretionary expense. Industry leaders contrasted the $31 billion annual price tag of global preparedness with the catastrophic multi-trillion-dollar cost of inaction.

“Preparedness does not begin when a crisis hits,” said Reddy, citing industry calculations estimating that the overall economic cost of COVID-19 amounts to $13.8 trillion globally.

“It is built through the choices countries make every day to value innovation and invest in resilient health systems.”

Soaring defence budgets and plunging health aid

This warning comes as funding is being rebalanced towards national defence spending, while global development assistance is contracting sharply. Net official development assistance (ODA) is projected to drop 6.9% in 2026 following a record 23.3% collapse in 2025, according to OECD data. Sectoral health aid faces the deepest cuts of all, projected to fall between 29% and 46% from 2024 levels, pulling global health funding well below pre-pandemic baselines.

In contrast, global military expenditure reached an all-time high of $2.89 trillion in 2025 after eleven consecutive years of growth, according to Stockholm International Peace Research Institute data.

Paul Friedrichs, Rand Corporation

Noting that meeting annual global health security needs ($31 billion) represents just 1% of world military spending, Paul Friedrichs, senior biopreparedness fellow at the RAND Corporation and former White House pandemic advisor, urged governments to view biodefence as a strategic national security investment rather than a discretionary health expenditure.

Eliminating friction for 100-day response

As biological threats compound, Coalition for Epidemic Preparedness Innovations (CEPI) chair Jane Halton warned that global health security faces “genuine gaps in governance and oversight” alongside critical delays in outbreak response.

To operationalize the G7- and G20-backed 100-Day Mission, CEPI advocates eliminating administrative “white space” by pre-positioning clinical trial networks and establishing “R&D safe harbours” that grant scientists immediate pathogen data access on day zero.

Jane Halton, CEPI chair.

Under CEPI’s proposed framework, developers would defer full PABS benefit-sharing obligations until reaching defined downstream commercialization thresholds, preventing upfront contractual negotiations from stalling early R&D.

“When it comes to these risks, you need three words: Speed, speed, speed,” emphasised Halton during the panel debate.

Debate over speed and industry red lines

Sustaining high-risk pharmaceutical R&D and overcoming antibiotic development hurdles requires viewing health security as a strategic national investment.
Sustaining high-risk pharmaceutical R&D and overcoming antibiotic development hurdles requires viewing health security as a strategic national investment.

Differing slightly from CEPI’s downstream trigger proposal, Reddy reiterated the pharmaceutical industry’s central red line in pandemic negotiations: unhindered, day-zero access to pathogen genetic data without transactional preconditions or upfront compliance hurdles.

While supporting multilateral approaches to pandemic preparedness and health security, IFPMA maintains that contractual preconditions risk creating fatal research delays, arguing that actual emergency bottlenecks stem from regulation, financing, and supply logistics rather than data access.

Citing IFPMA data, Reddy emphasised that predictable intellectual property frameworks are essential to sustain high-risk private R&D, noting a 91% clinical failure rate for new drug candidates. Addressing the unique market dynamics of novel antibiotics, Kosaraju added that companies face up to 33 years to recover development investments.

To preserve research speed, industry advocates for a non-exclusive system that leverages existing open databases and WHO-coordinated laboratory networks, allowing manufacturers to enter voluntary partnerships and licensing agreements on mutually agreed terms rather than facing upfront contractual roadblocks.

The battle over binding PABS terms

Delegates debate the WHO Pandemic Agreement’s PABS System, balancing immediate pathogen data access for research against binding equity commitments for developing nations.

Negotiators from the Africa Group and the Group of Equity have consistently countered that voluntary mechanisms failed during COVID-19.

The WHO Pandemic Agreement, approved by member states in 2025, commits countries to providing 20% of needed medicines and vaccines to WHO for equitable distribution – 10% as donations and 10% at affordable prices, when the next such global threat emerges.

However, the precise mechanisms of how that will work were supposed to be defined by the PABS Annex. And over a year into negotiations, developing and high-income nations remain at odds as to exactly how to achieve those targets.

Developing nations continue to push for a legally binding PABS mechanism with mandatory technology transfers and binding requirements on manufacturers for allocations of their production – in exchange for access to pathogens sequences and data.

Many developed countries, meanwhile, have said that any constraints on the immediate sharing of pathogen data could hinder development of critical countermeasures – a position industry supports in principle.

Asserting health sovereignty in the Global South

Raji Tajudeen underscores African regional self-reliance.
Raji Tajudeen underscores African regional self-reliance.

Highlighting the lessons of recent health crises, Raji Tajudeen, head of public health institutes at Africa CDC, underscored that African states are asserting health sovereignty to build regional self-reliance. The Africa CDC is operationalising the African Medicines Agency and coordinating pooled regional procurement, supported by 28 African nations that recently mobilised over $130 million in domestic funds for the continental Ebola outbreak response.

These regional initiatives align with broader reform frameworks such as the Accra Reset and the Lusaka Agenda, which advocate treating health security as an essential global public good requiring country-led coordination. Yet, as collapsing development aid, proliferating biosecurity risks, and commercial impasses converge, global monitoring reveals that implementation continues to lag dangerously far behind political rhetoric.

“Infectious diseases cannot be dealt with one country at a time,” concluded Ihekweazu. “Sovereignty is not opposed to universality.”

See related story:

With Only Three ‘No’ Votes, UN Adopts Political Declaration on Pandemic Preparedness

Image Credits: U.S. Army National Guard/Edwin L. Wriston, Felix Sassmannshausen/HPW, WHS/HPW, European Union, WHO / Mark Nieuwenhof.

A child is marked by a healthcare official after receiving the polio vaccination.

A polio-free Africa is within reach, but only if we make it a priority. Ending the disease will not only protect our children, but it will also strengthen our health systems and safeguard us against future threats. The Ebola outbreak in Central Africa, with several cases of polio lurking in the shadows, remains an instructive lesson to keep in mind for World Polio Day, October 24, and after.

The urgent Ebola outbreak in Central Africa may be demanding attention, but polio, a disease without a cure, is a threat that has yet to completely disappear. Just this month, the poliovirus has been detected in six African countries this month, including DR Congo and Nigeria, and, earlier this year, in Australia, the United Kingdom, Malawi, Zambia, and South Africa.

Polio is caused by a virus that can invade the nervous system and cause paralysis in a matter of days, but fortunately there is an effective vaccine that drives our efforts to stop the spread of this disease. In particular, the detection and response at the start of the year in Blantyre, Malawi, reflected everything we strive to do on the ground. The poliovirus was detected from an environmental sample collected from the city’s sewage system. The government response, a political priority, centered on an intensive four-day immunization campaign that reached 1.3 million children and transmission was eventually averted.

The polio paradox

Polio
Polio cases are falling, but there remains persistent wild poliovirus transmission in Afghanistan and Pakistan, as well as vaccine-derived outbreaks elsewhere, while funding gaps impede global eradication goals.

Today, the “wild” version of the polio virus remains endemic in only two countries, Afghanistan and Pakistan. However, an outbreak of wild poliovirus in East Africa in 2022 linked to the importation of wild poliovirus from Pakistan, and triggering a massive multi-country immunization campaign, shows how easily progress can be threatened when gaps in vaccination coverage persist.

Most vaccine-derived infections that we see emerging today also come from virus strains that result from less than optimal immunization coverage. Efforts to vaccinate communities are often disrupted by conflict, natural disasters, cross-border migration, poor access to health services, and vaccine hesitancy. The consequences of these will lead to persistent transmission coupled with the emergence of new virus strains.

Thus, we live with a paradox: The oral polio vaccine that has been our most powerful tool in driving poliovirus to the brink of eradication globally can also circulate, mutate and regain virulence in areas with inadequate vaccination coverage. This paradox doesn’t diminish the value of oral polio vaccination, rather it underscores the urgency of achieving and sustaining high coverage. It also highlights the importance of innovation, such as the introduction in 2021 of the novel polio vaccine (nOPV2), designed to be more stable and reduce the risk of reversion to virulence.

In the 1950s, the poliovirus killed or paralyzed half a million people around the world every year. In 2024, between the “wild” strains and “vaccine-derived” strains derived from suboptimal immunizations, more than 500 polio infections were confirmed around the world.

Outsized progress despite diminished resources

At the mouth of Lokaro Bay, a place in the Taolagnaro district of the Anosy region of Madagascar. On May 13, 2024, the official launch of the Anosy region’s polio vaccination campaign took place. At just 19 years old, Laha Elersene Razafimahavory is a champion of childhood immunization.

In late 2024 and early 2025, we faced a steep reduction in global health and foreign aid from a number of donor countries. The impact of these cuts can be seen clearly in many health outreach programs.

However, by this point in 2025, countries had worked together to vaccinate nearly 200 million under-five children across sub-Saharan Africa. In the Democratic Republic of Congo, type 1 cases fell from 149 in 2022 to just one case in 2025.

In the first half of 2026, we have noted significant and continued progress towards the eradication of poliomyelitis in our Region. Polio detections are down 33% since 2024, but rising detections of polio types 1 and 3 remain a concern. Moreover, outbreaks in Burundi, Ghana, Guinea-Bissau, Republic of Congo, and Uganda were successfully closed.

In the Horn of Africa, persistent outbreaks are driven by low immunity, population displacement, and limited access to health services. But between February and April 2025, a massive, coordinated campaign reached over 18 million children across Djibouti, Ethiopia, Kenya, and Somalia, demonstrating the power of regional solidarity. In May of this year, Ethiopia reached an additional 1 million children in border areas and refugee camps.

Overall, 168 million children in sub-Saharan Africa received at least one dose of the polio vaccine between January and September 2026, with vaccination campaigns conducted in 22 countries. This includes cross-border immunization campaigns in March that vaccinated 10 million children in Angola, the Democratic Republic of Congo and Namibia after laboratory testing confirmed more than three dozen polio cases were genetically linked.

A four-point strategy to continue momentum

Health surveillance assistants prepare the oral polio vaccine before heading out on foot to vaccinate children under the age of 10.

Our efforts to end polio are under pressure, though, without secure global funding. Many countries are working to maintain sensitive surveillance, resilient laboratories, and rapid response systems. Securing long-term funding to fill key gaps and keep the polio programme running, even after eradication, remains one of four strategic imperatives.

Making the most of polio investments remains a priority. As the Democratic Republic of the Congo continues to respond to the latest Ebola outbreak, the infrastructure, expertise and community networks built through decades of polio eradication efforts provide a foundation for surveillance and emergency coordination, reinforcing national response efforts in a highly complex operational environment.

At the same time, the outbreak highlights the broader value of polio investments. Amid ongoing global funding constraints, sustaining these capacities is essential not only to achieve a polio-free world, but also to strengthen health security and protect communities from current and future public health threats.

Polio vaccination campaign in Malawi 2022

We also need to work better across borders. We will improve coordination among countries with migratory populations, such as the Lake Chad Basin region, by coordinating vaccination campaigns, sharing data, and reaching children on the move or in hard-to-reach areas.

And lastly, improving testing and tracking is critical. We must invest in stronger labs and faster virus detection across the region. Better sample transport and more local testing will help us act quickly when outbreaks happen.

A polio-free Africa is within reach, but only if we make it a priority and remain steadfast in these last miles. Ending the disease will not only protect our children, but it will also strengthen our health systems and safeguard us against future threats. This is something we need to remember in particular this week, as we observe World Polio Day on 24 October – with several cases of polio lurking in the shadows of the Ebola epidemic in Central Africa.

As a cardiologist who has spent many a day listening to hearts, I’ve learned one vital truth—prevention is everything. With strong leadership, community support, and strengthened partnerships, we can protect our children and show Africa’s strength in global health.

Dr Mohamed Janabi is the WHO Regional Director for Africa.

Image Credits: UN Photo/JC McIlwaine, WHO Africa, WHO.

Who will steer the World Health Organization through its next chapter? Explore Health Policy Watch’s daily series examining the platforms, records, and institutional hurdles facing each contender for WHO Director-General, continuing today with Dr María Neira. Access all candidate profiles on our dedicated election site.

Championing primary prevention: Dr María Neira’s platform calls for using WHO’s normative authority to direct global capital toward environmental drivers before populations become patients.
Championing primary prevention: Neira’s platform calls for using WHO’s normative authority to direct global capital toward environmental drivers before populations become patients.

The nomination of Dr María Neira by Spain introduces a distinct leadership paradigm to the WHO Director-General race. As former director of WHO’s Department of Environment, Climate Change and Health (2005-2025) and a former Spanish vice minister of health, she enters the election as an internationally recognised authority on primary prevention and planetary health. Backed by a broad coalition of civil society groups and scientific networks, Neira has formally launched her official manifesto, “Global Health Vision,” alongside her presentations at the World Health Summit in Berlin and responses to Health Policy Watch.

Anchored by her central proposition that “health should be the compass for a changing world,” her platform asserts that WHO must move beyond reactive emergency response to drive primary prevention and strengthen country-level capacity to act. Positioning environmental health as the frontline of disease control, Neira frames climate resilience, clean water, and primary prevention not merely as environmental policies, but as WHO’s most essential bulwark against cascading global health emergencies and increased pandemic threats.

However, her central challenge will be convincing sceptical and disengaged member states that a candidate propelled by civil society can govern as a pragmatic realist, capable of steering an agency confronting severe budget contraction, geopolitical pushback against climate policies, and structural overextension.

Blueprint for primary prevention and planetary health

From frontline waterborne disease response to Geneva executive leadership, Neira’s career bridges field environmental health with top-tier global policy.
From frontline waterborne disease response to Geneva executive leadership, Neira’s career bridges field environmental health with top-tier global policy.

Neira’s official manifesto sets out five commitments to guide the WHO towards a more focused and accountable future:

  1. Primary prevention as a fiscal strategy: Her platform elevates clean air, heat protection, universal safe drinking water, and sanitation as non-negotiable health baselines, while addressing NCD risk factors (tobacco, alcohol, unhealthy diets, physical inactivity). She advocates using WHO’s normative authority to evaluate the health impact of investments in non-health sectors – such as energy, agriculture, transport, and urban planning – reframing prevention not as a financial burden, but as a foundation for prosperous, resilient economies.
  2. Data integration and AI governance: The manifesto calls for deploying artificial intelligence and advanced analytics to consolidate WHO’s dispersed technical guidance and databases, making actionable evidence directly accessible to country ministries. It also advocates for WHO to lead in setting global governance standards for AI in healthcare while safeguarding independent scientific advice from political or financial interference.
  3. Country-level delivery over headquarters directives: Shifting evaluation toward measurable national outcomes, Neira’s platform focuses on building sustainable local capabilities – including public health institutions, surveillance networks, regulatory bodies, and supply chains. It explicitly emphasises investment in the full multidisciplinary health workforce, from clinical specialists to community health workers, as essential to national health security.
  4. Institutional focus and predictable financing: Addressing WHO’s structural and financial constraints, the platform proposes concentrating resources on core areas of unique organisational value while consolidating or sunsetting redundant activities. On financing, Neira supports the agreed target of funding 50% of WHO’s base budget through assessed contributions, alongside flexible voluntary funding and regular Executive Board performance reviews.
  5. Workplace integrity and technical impartiality: Regarding internal administration, the manifesto outlines zero-tolerance policies for harassment, bullying, and discrimination, backed by independent reporting and anti-retaliation mechanisms. Neira stresses that WHO must maintain technical impartiality across all member states and conflict zones, keeping assessments independent of political considerations.

To translate these principles into immediate momentum, Neira pledged in Berlin that within her first 100 days she will establish a specialised internal “antenna” to detect non-traditional health risks – specifically targeting declining global fertility rates, endocrine-disrupting chemicals, microplastics, and artificial intelligence (AI).

By placing normative leverage and primary prevention at the heart of her programme, Neira offers a blueprint designed to maximise WHO’s global reach even within the sharp realities of multilateral austerity.

From conflict zones to two decades at WHO’s Geneva core

From Médecins Sans Frontières conflict zones to WHO executive leadership, Neira leverages deep institutional knowledge to guide policy.
From conflict zones to WHO executive leadership, Neira leverages deep institutional knowledge to guide policy.

Her campaign focus is grounded in a career that bridges frontline medical crises and top-tier global health diplomacy. Born in 1962 in Asturias, Spain, Neira completed her medical degree at the University of Oviedo before specialising in endocrinology in Paris.

She forged her early professional commitment in active conflict zones, serving as medical coordinator for Médecins Sans Frontières (MSF) in refugee camps across El Salvador and Honduras. Subsequently, Neira spent five years as a public health adviser to the Ministry of Health in Mozambique, followed by service as a UN public health adviser for UNDP in Rwanda.

Her multilateral career began in 1993 when she joined WHO in Geneva as coordinator of the Global Task Force on Cholera Control, later directing the Department of Control, Prevention and Eradication. In 2002, she returned to Spain to serve as vice minister for health and consumer affairs and founding president of the Spanish Food Safety Agency (AESA, now the Food Safety and Nutrition Agency AESAN). Here, she managed national health protection and nutrition policy grounded in the universal, publicly funded principles of Spain’s national health system.

Recruited back to Geneva in 2005 as director of WHO’s Department of Environment, Climate Change and Health, Neira spent two decades leading global initiatives on climate change, air pollution, sanitation, and occupational safety. During this tenure, she played a central role in embedding public health commitments within the Paris Climate Agreement, establishing the Alliance for Transformative Action on Climate and Health, and spearheading the global One Health framework.

Domestic campaign challenges

Domestic political deliberations in Madrid delayed Neira’s nomination as Spain simultaneously backed high-profile candidates for leadership posts across other UN agencies.
Domestic political deliberations in Madrid delayed Neira’s nomination as Spain simultaneously backed high-profile candidates for leadership posts across other UN agencies.

Notwithstanding her technical credentials, Neira’s candidacy faces distinct political and strategic hurdles as the election campaign unfolds.

Spain presents a mixed financial backdrop: Madrid’s overall recorded WHO budget envelope contracted from $42.81 million (2024-2025) to $37.57 million (2026-2027) due to shrinking voluntary contributions. Aligning with Neira’s emphasis on sustainable core financing, the Spanish government has simultaneously demonstrated firm statutory commitment by steadily raising its mandated assessed contributions from $20.54 million to $26.11 million over the same period.

Despite this financial track record, domestic political dynamics in Madrid reportedly created ministerial delays regarding her nomination. The Spanish government had simultaneously mounted high-profile campaigns for other UN agency leadership posts – nominating labour minister Yolanda Díaz to lead the International Labour Organization (ILO) and agriculture minister Luis Planas to head the Food and Agriculture Organization (FAO). Running multiple parallel UN campaigns risks diluting Spain’s political leverage across voting caucuses, a challenge further complicated by domestic political headwinds facing the Spanish government.

Multilateral hurdles and the civil society counterweight

Multilateral headwinds: While European vote-splitting and diplomatic friction challenge Neira’s candidacy, civil society endorsement provides a key counterweight.
Multilateral headwinds: While European vote-splitting and diplomatic friction challenge Neira’s candidacy, civil society endorsement provides a key counterweight.

Institutionally, Neira faces scrutiny over her background as a two-decade Geneva insider (2005-2025). Despite her standing as a planetary health authority, health’s share of multilateral climate finance stagnated during her tenure, while her WHO department underwent administrative downsizing and structural merger.

Politically, European member states do not vote as a unified bloc, and with two nominees from the region – Neira and Belgium’s Hans Kluge – the European vote is fragmented. Beyond regional vote-splitting, Neira must navigate re-engagement with key powers – including the United States following its withdrawal and shifting domestic stance on international climate policy and multilateral funding – as well as scepticism from Global South and industrializing nations concerned that an aggressive environmental health agenda could constrain economic development.

Addressing these concerns in a response to Health Policy Watch, Neira frames planetary health as a pragmatic, economic agenda. Pointing out that “health is increasingly engineered outside the health sector,” she advocates using WHO’s normative authority to demonstrate the direct financial dividends of primary prevention before populations require clinical care. Investments in clean air, extreme heat protection, universal safe water, and climate-resilient health systems represent “no-regrets investments” that protect fiscal budgets and national productivity, regardless of a government’s stance in international climate negotiations.

Balancing these hurdles are distinct coalition strengths. Strong backing from civil society organisations and environmental health networks provides grassroots momentum, though it risks alienating more conservative Member States. Simultaneously, women’s advocacy networks and gender equity groups are mobilizing around her bid to lead an organisation where only two women – Gro Harlem Brundtland and Margaret Chan – have ever served as Director-General in its nearly eight-decade history.

A ‘compass for a changing world’?

By formally registering Neira’s nomination, Madrid provided the official statutory vehicle for a campaign underpinned by a broad global coalition of scientific societies, indigenous advocates, elders’ rights coalitions, and environmental health networks across the Global North and Global South.

Yet her status as a two-decade Geneva headquarters veteran remains a significant point of friction. To member states demanding operational decentralisation, fiscal austerity, and an end to top-down directives, an executive rooted in Geneva’s normative corridors and propelled by activist networks risks being perceived as detached from frontline, country-level realities.

Her viability hinges on convincing sceptical capitals that a headquarters insider can step outside the Geneva bubble to govern with clear-eyed pragmatism – proving that primary prevention and planetary health are hard-nosed fiscal buffers against disease. Ultimately, her candidacy offers member states a distinct strategic choice: electing a physician-environmentalist who asserts that “health should be the compass for a changing world” to reposition primary prevention and planetary health as central drivers of global health policy.

Note: This article incorporates research findings and comparative evaluations from Rifat Hossain. Profiles will be updated as the campaign progresses, stay tuned on the microsite.

Image Credits: WHO, Pixelshot via Canva, Yeray Díaz Zbida, WHO/Antoine Tardy .