World Health Organization Director General Margaret Chan addressing the World Health Assembly in Geneva. (Valentin Flauraud / Courtesy Reuters)
After 15 years of heralded progress on pandemic preparedness, tuberculosis control, tobacco regulation, and health metrics, the World Health Organization faces confusion over its future. In 2011, after a yearlong consultation with member states, WHO Director-General Margaret Chan described the agency as overextended and unable to respond with speed and agility to today's global health challenges. The most serious examples: the WHO's inability to address noncommunicable disease (NCD) prevention globally, to improve access to health systems, and to set global priorities in health.
In the years after the WHO was founded in 1948, the organization plucked a lot of low-hanging fruit. It helped governments improve hygiene and environmental health. It also supported the development and application of new technologies to control major infectious diseases such as malaria, syphilis, tuberculosis, and yaws. These missions largely went hand in hand with postwar reconstruction efforts. The WHO's most cited success from its early years was its initiative to eradicate smallpox, which began in 1958 and was certified complete in 1979.
Yet even in this golden era, the WHO struggled with an internal debate over its fundamental mission. There was an ongoing tension between a "vertical" approach, which tackled specific diseases without addressing general health services and prevention needs, and a "horizontal" one, which looked to strengthen whole health systems and support basic-care services that would deliver broad-based, integrative, and long-term improvements in public health. Bilateral donors in particular favored vertical interventions because measurable results were easier to demonstrate over a short time frame, by quantifying, say, the number of bed nets delivered or vaccines administered. These programs are also easier to control, given that they typically have separate funding proposal and allocation processes, delivery systems, and budgets. However, champions of primary care believed the WHO should dedicate resources and efforts to a horizontal approach because short-term advances in certain diseases or vaccination coverage run the risk of fragmenting general health services
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