By Laurie Garrett, special to Humanosphere

With the future of global health more uncertain than it has been in more than a decade, the first hats have been tossed into the election ring for top leadership at the World Health Organization. It is a dire time for WHO, which has seen its financial and political support erode steadily for the last decade, its credibility suffering mightily over its slow and sloppy response to the 2014 Ebola outbreak.

Everybody is talking about how best to reform the WHO, arguably the best vehicle for coordinating the ever-changing global health agenda. But a new election process using secret ballots for appointing the next director-general is hardly a promising start.

The director-general (DG) vote will take place at the World Health Assembly in May 2017 in an unprecedented, one-country-one-vote procedure conducted via secret ballots. Some are concerned this new, secretive process is unlikely to produce a leader who can restore the WHO’s position of global leadership, its respect, authority and financing.

How the leader of the World Health Organization is chosen

For the first time since it was founded in 1948, the WHO will select a new DG via a process that gives Niue, population of 1,612, an equal vote with China, population of 1.4 billion – and Lichtenstein, population 33,720, equal voting power with India, population 1.25 billion.

Procedurally, candidates have until September to formally put their names in nomination and will campaign around the world throughout the fall and winter of 2016. In mid-January, the 34 members of the WHO executive board (which includes China and some of the largest donors: the United States, United Kingdom, Japan, Sweden and France) will formally interview the candidates, selecting three finalists. The finalists will then have five undoubtedly peripatetic and frantic months to make their cases all over the world.

And then, for the first time in its history, the 194 members of the World Health Assembly will vote, by secret electronic ballot, choosing the next leader, who will formally take the helm at WHO in Geneva on July 1, 2017.

Previously, the WHO’s leaders were selected by the executive board, and merely ratified by the Assembly five months later. The 34 nations lucky enough to have seats on the executive board during an election cycle held enormous power and were subjected to spectacular appeals, including overt bribery. Under Rules 48 and 52 of the WHO procedural guidelines, the executive board members, most of whom are ministers or secretaries of health from their respective nations, would write down their votes on sealed ballots, often through several rounds of debate and voting, until a nominee drew a majority.

For decades, the WHO election process has been denounced as corrupt. Some countries have challenged it on the grounds that undue clout is given to a handful of ministers operating in secrecy. In particular, poor nations complained that the United States and other wealthy countries had too much influence over the selection of top candidates and ultimate voting. So in December 2015, the executive board issued new voting guidelines, updated from a reform process that the board initiated three years earlier.

Allegations of bribery have taken many forms over the decades and largely been the subject of whispers and winks, with no serious public scrutiny or investigation.

I personally witnessed an incident in 1991, when DG Hiroshi Nakajima’s Japanese government backers were trying to promote re-election of the much-reviled WHO director. I was then a reporter for Newsday, doing research at WHO headquarters in Geneva. Beneath the grand marble staircase that descends from the building’s mammoth entry to a lower level leading to its meeting hall was a private conference room, post office and newsstand. I was in a queue at the post office when the conference room door flung open at my back and an enormous rolled rug flew out, narrowly missing me and landing with a loud thud that couldn’t cover the sound of an African minister of health’s roaring voice.

“A rug! A rug?” the large East African woman shouted at a trio of Japanese diplomats scampering out of the chamber. “You think you can buy my vote with a rug? Do you think I am that cheap?”

The enraged minister then loudly delineated a list of “promises” (a.k.a. bribes) the Japanese had reportedly made to other voting members of the executive board, including construction of a hospital, payment of school fees for the children of Switzerland-based nationals employed at WHO, promised employment in plush Geneva for friends and family of the would-be voter and a range of big construction projects. The episode was astounding not because it transpired, but that it did so in front of many witnesses, including an American journalist.

None of the former candidates for DG has publicly described bribes and demands made in the past – I wish they would. But many past nominees and their campaign staff have spoken to me off-the-record, describing health and development projects built in poorer countries as “payment” for their ministers’ votes on behalf of a candidate from a middle-income or wealthy nation. There is code language used in global health diplomatic circles to describe why seemingly outstanding candidates in past elections failed to garner executive board votes – “the country didn’t give him/her sufficient support.”

One former candidate whose government had strong anti-bribery laws told me that a voting minister approached him at a reception, suggesting that in lieu of cash or a promised major construction project in his country, the vote could be had in exchange for a vow to place the minister in a cushy position in WHO headquarters with sufficient stipends to cover posh housing, private schooling for all his children and relocation costs. A diplomat from one of WHO’s largest donors detailed a litany of such promises made, and fulfilled, by past DG candidates, resulting in appointments of over-paid, ill-qualified managers scattered among the 7,000-employee WHO Secretariat. The campaign manager for another excellent past nominee complained that the winning candidate’s country built hundreds of millions of dollars’ worth of projects across Africa to garner votes.

While I have never been provided with evidence that the most powerful donors have thrown money at candidates, there have been choices made, I have repeatedly been told, based on political issues well outside of the health arena. The United States, Germany, the United Kingdom, Japan and other major donors have pushed agendas related to such matters as North Korean nuclear deterrence, Chinese trade negotiations and European Union relations with Russia and eastern regions – weighing their votes against larger political promises.

What is likely to happen now, if the process proceeds without any regulation or reform?

To date, three candidates, representing France, Ethiopia and Pakistan, have formally announced their candidacy, and many more have been discreetly exploring potential runs and are expected to nominate. From France, two-term former Minister of Health and one-term former Foreign Minister Philippe Douste-Blazy tossed his beret in the ring. Douste-Blazy has retained serious campaign professionals in Paris and Washington, D.C. and has been making his case around the world discreetly for several months, citing his leadership of UNITAID, the innovative financing scheme that underwrites HIV, TB and malaria treatment in poor countries.

Ethiopia’s current Foreign Affairs Minister (and former Minister of Health) Tedros Adhanom Ghebreyesus is in the running, and his government recently pressured the African Union to pledge all its 54 votes to Tedros. That move may have effectively knocked four other African rumored contenders out of the race – Senegal’s Minister of Health Awa Marie Coll-Seck, Rwandan Minister of Health Agnes Binagwaho, Nelson Mandela’s widow Graca Machel (formerly of Mozambique, now South Africa and former Chair of the Board of GAVI) and Mali’s Michel Sidibé who currently heads the U.N. AIDS program. There are indications, however, that the African Union solidarity behind Tedros is eroding, as African leaders tell me they are considering Francophone alliances or Eastern African interests. Moreover, Africa’s tremendous dependence on Chinese development projects and Sino-investment renders many countries vulnerable to messaging from Beijing, should the Xi government choose to flex its diplomatic muscle on behalf of a candidate other than Tedros.

From South Asia, former Pakistani Minister of Health Sania Nishtar has formally announced. As founder of the nongovernmental group Heartfile, Nishtar has been an impassioned promoter of the noncommunicable diseases agenda at WHO and is likely to garner support from middle-income nations that are struggling with aging populations and rising rates of cardiovascular diseases, cancer and diabetes.

More candidates are expected to join the fray over the next few months. Between now and January, the contenders will likely focus on the executive board members and nonmember major donors, making their cases for placement on the roster of the final three. This will mean spending time and money (presumably at their governments’ expenses, though there are no campaign finance disclosure rules in this game) traveling to Washington, D.C., Seattle (the Bill & Melinda Gates Foundation is the number two donor to WHO), London, Tirana, Buenos Aires, Ottawa, Beijing, Tokyo, Amman, Monrovia, Islamabad, Moscow, Pretoria, and the other capitals of the 34 member states. This portion of the DG race is expected to play out much as past WHO elections have.

But come January, all heck will break loose as the selected final three will embark on a process without precedent. While it’s inconceivable that campaigning could approach the astronomical costs of U.S. elections, the travel costs for candidates and their entourages will surely be in the tens of millions of dollars – unless the WHO executive board puts a cap on campaign spending.

To date, there is no discussion within the board of campaign spending caps or other procedures that might limit the more odious spending aspects of the January-to-May 2017 race. There are no campaign transparency rules. In its December 2015 meeting, the executive board ruled that WHO must pay the travel costs of candidates’ attendance to the January 2017 board meeting, but reached no decisions regarding any other aspects of campaign finance. There is no stipulation for disclosure – a candidate could theoretically run a campaign funded by pharmaceutical manufacturers, tobacco producers, an anti-patent BRICS consortium, a random billionaire or just about any other source.

The corrupting influence of money in politics is hardly unique to U.S. politics. The best antidote is transparency and public accountability. WHO appears to be moving in a direction that will only exacerbate the problems in its governance that have led to so many failures in recent years.

Assuming WHO candidates won’t waste their time applying further pressure to the executive board members after the January vote, 160 other nations – and 160 ministers of health – must be appealed to. Of the 13 nations in the world that have populations of more than 100 million people, six are on the executive board, leaving India, Indonesia, Brazil, Nigeria, Bangladesh, Mexico and the Philippines. Even if a candidate wins all 13 of the most populous nations on Earth, representing 4.65 billion people or 60.1 percent of the world, the nominee would remain 75 votes shy of a simple majority of the Assembly.

In recent years, voting blocs have arisen within the World Health Assembly, reflecting a variety of trends that candidates may be compelled to address. Regional blocs, bringing Asians, Africans and Latin Americans together, have long existed, and Tedros is counting on his region’s backing.

Strange bedfellows have recently combined forces on issues, including anti-Americanism. Malaysia, India, Libya and Venezuela have formed voting blocs targeting all patent provisions related to drugs and medical products and promoting technology transfer – they are occasionally joined by China, Brazil, Indonesia and a variety of other emerging market countries. The Eastern European countries have consistently opposed efforts to expand WHO financing or mandate programs that would pose costs to countries, often garnering backing from poorer African and Asian nations.

Overall, the assembly members are well aware that more than 75 percent of WHO financing comes from three sources: the United States government, the Gates Foundation and the government of the United Kingdom.

A complex pattern of resentment and entitlement surrounds the rest of the world’s reaction to this highly skewed dependency. The resentment implies that the three donors have outsized influence on WHO policies and global health, writ large. On the other hand, the world feels entitled to obtain and use wealth from the richest countries, and demands more of it. Candidates for WHO DG need the political support of the major donors, but cannot appear to answer to Washington, D.C., Seattle or London.

Before a new DG is chosen, the world will vote for a new secretary-general of the United Nations

The democratization of voting, allowing all nations to weigh in on the WHO leadership campaign, reflects a larger trend across the United Nations system. Historically, the elite Security Council selected new secretaries-general, whose naming was rubber-stamped by the all-nations General Assembly (much as the executive board chose WHO leaders, who were ratified by the Health Assembly).

Secrecy once surrounded the process. This year, for the first time, the nomination procedure is out in the open and an election process will be carried out openly in the Security Council in late September or early October. The new secretary-general will take office on January 1, 2017.

Nine candidates are in the running, seven of them from Eastern European countries. Four of the nine are women. It is possible that the U.N. may, for the first time in its seven decades’ history, be led by a female or an individual who grew up in a communist state.

There is no heir apparent or individual who appears to have curried special attention from current Secretary-General Ban Ki-moon. Former New Zealand Prime Minister Helen Clark has strong support based on her current leadership of the U.N. Development Program (UNDP). In that capacity, Clark ushered through the long and often chaotic Sustainable Development Goals process, resulting in 17 SDGs with 169 targets for 2030 achievement. UNESCO leader Irina Bokova – former Foreign Minister of Bulgaria – is also a strong contender.

Clark’s 2009 admission of Palestine in a nation-state role in UNESCO drew ire from both Israel and the Obama administration, resulting in a U.S. cutoff of funding for the U.N.’s culture agency. Bokova enjoys mixed support in her home country, where Bulgarian critics charge that her family played a prominent role in the communist, pro-Soviet era and continued to realize unusual benefits and wealth. Lurking in Bulgarian wings, not officially nominated, is Kristalina Georgieva, vice president of the European Commission. Other candidates include Igor Luksic, minister of foreign affairs of Montenegro; Portugal’s António Guterres, former U.N. high commissioner for refugees; Danilo Turk, former president of Slovenia; and three former foreign ministers: Vesna Pucic, of Croatia, Natalia Gherman of Moldova, and Srgjan Kerim of Macedonia.

Whoever takes over the U.N. will face a seemingly impossible scale of global catastrophe, sclerotic bureaucracy, corruption and poor morale rife throughout the system. In a recent, heart-wrenching essay, “I Love the U.N., but It Is Failing,” Anthony Banbury explained why he was resigning the No. 2 post after working in a variety of U.N. positions since 1988. Among his complaints was a bureaucracy that slowed transfer of vital personnel to tackle the Ebola epidemic. He warned that, “In the run-up to the election of a new secretary-general this year, it is essential that governments, and especially the permanent members of the Security Council, think carefully about what they want out of the United Nations. The organization is a Remington typewriter in a smartphone world. If it is going to advance the causes of peace, human rights, development and the climate, it needs a leader genuinely committed to reform.”

The issues that should be primary, but probably in this voting structure won’t matter at all

In September 2015, the United Nations General Assembly ratified the 17 Sustainable Development Goals (SDGs), with 169 targets for achievement by 2030. In December, the COP21 climate summit in Paris set a separate set of climate, energy and development targets. Combined, the initiatives will require trillions of dollars of investments and donor support if they are to be met.

How will this money be conjured? Can the health-related SDGs, coupled with ongoing global health initiatives such as The Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, a maternal and child health special fund, an outbreak and epidemic contingency fund, and many more priorities, proceed in the absence of full funding? If not, where will the necessary support come from?

A recent report from the International Health Metrics and Evaluation (IHME) group shows that total global health spending ceased to grow after the 2008-09 world financial crisis and decreased slightly in 2015, reaching just $36.4 billion.

)Between 2000 and 2009, global health support soared at roughly 11 percent annually, with most of the growth aimed at achievement of the MDGs, but at its current slowed pace of less than 1 percent annual growth, IHME projects a mere $64 billion will be available for global health by 2040.

A report prepared last year for the U.N. General Assembly projects that full implementation of the SDGs will be astoundingly expensive, totaling between $90 trillion and $120 trillion, or $6 trillion to $8 trillion a year for 15 years. In contrast, MDG spending by 2015 was roughly $400 billion, about half of which came from the United States government and the Bill & Melinda Gates Foundation. Most of the MDG spending occurred after 2005. Locally, countries committed from their own resources about $110 billion over the same period.

The high SDG price tag will come on top of an already existing $1 trillion in annual spending to support existing multilateral programs. Additional promises or calls for new global health spending include the creation of a replenishable WHO Contingency Fund for Emergencies of $100 million; and a $12 billion Global Financing Facility (GFF) in support of Every Woman Every Child, based in the World Bank. In addition, a January 2016 report from the National Academy of Medicine calls for annual expenditures of $4.5 billion for global outbreak and response capacity, and to obviate a catastrophic pandemic. The Rockefeller Foundation is promoting a new agenda linking climate, SDG and health efforts into a movement for Planetary Health.

Strong economic arguments in favor of investing in health and climate change action can easily be made, as inaction will result in tremendous loss of life, property and global trade and economics.

But health is costly, regardless of climate change: according to a WHO assessment, 100 million households are pushed into poverty annually by out-of-pocket health expenditures, and that sum is expected to rise as the burden of cancer, heart disease and other noncommunicable and chronic ailments soars all over the world. The same report reckons worldwide spending on health topped $6.9 trillion in 2011. Per capita medical spending for care and treatment tightly correlates with national GDP, with poorer nations spending less and vice versa. Improvements in per capita wealth invariably lead to greater per capita health spending.

Current spending on health, from all sources – individual pocketbooks, insurance, government, donor and charitable systems – is nearly $7 trillion, or more than 10 percent of the world economy (reckoned at $60 trillion, for all trade and assets). Nearly half of that health spending, $3 trillion, is in the United States, where it accounts for 17 percent of GDP. Achieving SDG health targets, such as provision of universal health coverage for every person on Earth, would surely compel enormous front-end increases in expenditure all over the world before back-end savings, thanks to smart health financing, are realized.

At a minimum, funding for the SDGs and climate agreements, on top of maintenance of current multilateral health and development programs, would require targeted spending of roughly 15 percent to 16 percent of total global GDP annually for 15 years. While that’s less than the 17 percent of GDP the U.S. spends on health, ours is hardly an efficient system that should serve as a global model. Moreover, such an extraordinary diversion of wealth during peacetime has never occurred. World War II commanded tremendous diversion, with the United States expending 52 percent of 1945 GDP for its war effort, the United Kingdom reaching more than 70 percent war spending that year, and the entire world economy skewed dramatically to military expenditures. It is hard to imagine political leaders and legislative bodies committing to a peacetime diversion of world GDP of 15 years.

Finally, the concentration of global wealth into an ever-shrinking pool of ultra-rich individuals, companies and sovereign wealth funds has effectively decreased the global tax base, accessible for financing public goods. This point is underscored in arguments about middle-income country access to discounted medicines and medical supplies, where it is noted that rising national GDP often fails to lift wealth for the general population and GDP masks financial growth that overwhelmingly benefits a small oligarchy.

Further, elite wealth is often deliberately hidden in tax havens, inaccessible as government revenue source. By one reckoning, between $21 trillion and $32 trillion are so-hidden at this time. The Congressional Research Service estimated in 2015 that wealth hidden in havens cost the United States government more than $100 billion in annual tax revenues.

The Norwegian Agency for Development estimates that illicit cash from poor countries, alone, equal a sum more than ten times total global health and development assistance, meaning more money by an order of magnitude is extracted from poor countries than is applied to their assistance. The International Monetary Fund argues that the entire architecture of corporate and other transnational taxation must be overhauled. Promisingly, the IMF, World Bank and G20 announced in April 2016 a joint effort aimed at identifying and closing tax loopholes and havens. That move followed leaks of the so-called Panama Papers detailing worldwide money laundering that might well be hiding fourteen percent of world wealth from taxation.

Two changes needed: WHO election process must focus on secret balloting and campaign financing

There is no legitimate reason that World Health Assembly voting needs to be secret. Protecting governments’ voting privacy offers no positive outcome – a government minister is not voting as a private citizen, but as an accountable representative of his head-of-state, cabinet and, ultimately, population.

Secrecy can only enhance corruption opportunities, allowing country representatives to cast votes in direct contradiction to their own government policies, political promises made with other players, even bribes received. For example, Ethiopia’s hopes of winning the DG position for Tedros rely on the African Union member nations’ full compliance with their collective promise to vote for him, but secret balloting allows AU members to break that vow without Addis Ababa knowing they have done so. Nations may receive large development investments as condition for their votes, and secret voting protects all parties from scrutiny. If a voting minister ends up garnering a cushy position in Geneva after an election, there is no public way to demonstrate a possible quid pro quo link to the individual’s voting. In theory, secret voting allows ministers to cast votes that are in contradiction to orders from their own presidents or prime ministers.

Claiming that the rationale behind this new secret one-nation-one-vote system is “transparency and accountability” is akin to 2008 hedge funds asking investors to trust the value of their secretly bundled mortgage assets. Secrecy and transparency simply do not mix.

Financing of campaigns also ought to be transparent. The WHO Executive Board need not cap candidate spending, but it should demand full disclosure of all spending and support for candidates’ travel, accommodations, entertainment, publicity, staff payroll, election consultants and other costs. Assuming the three finalists will address the World Health Assembly before the nations cast their ballots, each should be required to provide the assembly at that time with a detailed breakdown on sources of funding and expenditures.

It may never be possible to eliminate the hand-shake deals that place individuals in plush Geneva jobs in exchange for their votes, stop linking donors’ largesse to voting quid pro quos or decouple selection of top U.N. posts from powerful nations’ geopolitical chess games. But the aspiration of strong, wise leadership at the helm of the struggling World Health Organization cannot be fulfilled merely by creating a second phase of all-nations secret balloting.

Behind the scenes finagling will, of course, continue. The world’s power blocs have interests in dozens of non-health issues that will arise in voters’ negotiations: terrorism; Middle East balances of power; world trade negotiations and treaties; leadership of other top multilateral positions such as UNDP, UNESCO and the U.N., itself; global financial markets regulation; nuclear proliferation; carbon trading and COP21 agreements; fossil fuels access and resources scrambles.

Because the United States will be in the throes of its national elections and in government transition during the WHO election process, the U.N. agency’s top donor is not likely to play a major role in the 2016-17 process. Therefore, policy initiatives aimed at influencing the United States government’s actions will be of limited value – especially if Republican Donald Trump is elected president of the United States.

Some immediate options for pressuring positive movement in WHO leadership selection process include:

Japan will soon host the G7 Japan 2016 Ise-Shima Summit, and the Shinzo Abe government has placed strong emphasis on health security. The G7 should publicly oppose secret WHO balloting and call for full campaign financing disclosure.

China is the current host of the G20, and its nominee, Dr. Margaret Chan, is the outgoing leader of WHO. The G20 should also publicly oppose secret WHO balloting and call for full campaign financing disclosure.

The American Public Health Association should take the lead immediately, reaching out to its counterpart national health societies around the world to call for genuine transparency and accountability in the WHO leadership selection, elimination of secret balloting and full spending disclosure.

Prominent civil society groups and nongovernmental organizations that are pivotal to global health, such as Doctors Without Borders, CARE, World Vision, International Medical Corps, International Rescue Committee, OXFAM, Treatment Action Coalition and hundreds more should embrace this challenge, calling upon the WHO Executive Board to ensure genuine transparency.

Inside countries, civil society groups involved in health issues should demand that their minister of health openly disclose his or her vote for WHO leadership and provide local journalists with details regarding any promises or deals struck in relation to the election.

Nongovernment donors, such as the Bill & Melinda Gates Foundation and the Rockefeller Foundation, should publicly join in the call for full transparency, cessation of secret balloting and campaign finance disclosure.

The window of opportunity for steering this process in a direction that might yield the sort of leadership that can navigate the ailing World Health Organization through the dangerous seas ahead is closing.

Many individuals and organizations have filled Op-Ed pages and health journals with critiques of WHO’s performance in the Ebola epidemic and decried governance of its regional offices. The Zika pandemic has revealed the deep credibility chasm that WHO has sunk into, as it is unable to raise more than 3 million of its requested $25 million to fight the mosquito-borne virus. The U.N. secretary-general race will grab more attention and possibly spawn trade-off agreements related to countries’ WHO votes. And all would-be World Health Organization director-generals have just four more months to garner backing and toss their hats into the campaign ring.

If the world health community wants a strong, well-financed, effective World Health Organization, it must act now. If not, shrug, ignore, and the world will get the health leadership it pays for– literally.

Laurie Garrett is a senior fellow at the Council on Foreign Relations where she directs the think tank’s global health program. Author of the acclaimed books The Coming Plague and Betrayal of Trust, Garrett is a prize-winning journalist whose recognitions include the Pulitzer, Peabody and Polk awards.