Who should be doing what in international health: a confusion of mandates in the United Nations?

Since 1945 at least five United Nations organisations have become substantially involved in international health activities. This has led to considerable confusion among policy makers, scholars, and UN staff over their distinct and appropriate mandates. Interviews with staff and a historical analysis have shown that while formal mandates have been complementary, effective mandates have led to an unclear delineation of activities. The processes of translating formal into effective mandates have been influenced by the decentralised nature of the UN, lack of a master plan for its activities, the considerable growth in the policy agenda, and the shift towards a multisectoral approach to health. The identification of each organisation's comparative advantage, at both the global and country levels, is one way of understanding what each organisation does best and perhaps should be doing. There is a need for improved mechanisms to define effective mandates, taking into account comparative advantages, if the mandates of UN organisations are appropriate to meet future challenges in international health.

There has been much recent reflection on and criticism of the World Health Organisation (WHO) and its role in international health.1 What much of this criticism has failed to acknowledge is that the WHO is no longer the only major player in this field and that many of the other players have ceased to regard the WHO as the captain of the team.

Much has changed in the UN during the past 50 years. In 1948 the WHO was created as the UN specialised agency in health. Five decades on international health has become crowded with other organisations—notably, the UN Children's Fund, Unicef; the World Bank; the UN Population Fund, UNFPA; and the UN Development Programme, UNDP. All four have active roles in international health but may also at times duplicate activities, compete instead of cooperate, …