Background

As the election for the next Director-General of the World Health Organization (WHO) approaches, movements are underway to re-examine the historical trajectory of international health governance. This discussion was triggered by an 'Offline' column by Richard Horton, Editor-in-Chief of The Lancet, which analyzed the actions of past leaders while discussing the upcoming leadership selection. The piece began its analysis with the 4th Director-General, Hiroshi Nakajima, who served from 1988 to 1998. Health policy researchers have raised concerns that it is difficult to find a complete direction for the future without acknowledging the achievements of the 3rd Director-General, Halfdan Mahler, who led the organization for 15 years and laid the foundation for modern public health.

In the current era of health security crises, retreating multilateralism, and geopolitical fragmentation, voices questioning the purpose and mission of international organizations are louder than ever. During the COVID-19 pandemic, global health inequality deepened as countries closed borders and focused on nationalistic vaccine procurement. The leadership of international organizations in responding to transnational health crises is faltering. Revisiting the insights of past leaders who practiced health justice beyond simple administrative management serves as an essential compass for future health diplomacy and policy establishment.

Key Findings

This letter focuses on the historical legacy of former Director-General Mahler, who led the organization for three terms from 1973 to 1988. While Editor Horton highlighted the perspective of modern bureaucratic leadership following former President Nakajima, he emphasized that the philosophy and structural resolve established by former President Mahler are the core assets to be inherited by the next leader. Although Mahler's tenure coincided with the height of ideological confrontation during the US-Soviet Cold War, he instead secured an agreement defining health as a fundamental human right.

A notable achievement was the international conference held in Alma-Ata (Alma-Ata) in the former Soviet Union in 1978 and the Alma-Ata Declaration adopted on its basis. Dr. Halfdan Mahler, then Director-General, articulated the bold goal of "Health for All by the Year 2000" and systematized the concept of Primary Health Care (PHC). It marks a paradigm shift that has redirected resources, previously concentrated in high-cost large hospitals and technology-centric curative medicine, toward community-based prevention, basic hygiene, and essential care.

He also laid the groundwork in the field of access to medicines. A prime example is the world's first Model List of Essential Medicines, established in 1977. A system was established to define essential medicines as public goods and support health authorities in various countries, including developing nations, in procuring high-quality drugs at appropriate costs. This is evaluated as a decisive action that protected public health priorities despite commercial pressure from multinational pharmaceutical companies.

Significance and Outlook

Mahler's public health philosophy offers principles for navigating the governance crisis that the next leader will face. The current international health environment faces multi-layered challenges, including the diversification of infectious diseases due to the climate crisis, the increasing burden of chronic diseases, and the expansion of AI-based digital healthcare. Despite advancements in high-tech medical technology, the collapse of basic medical infrastructure and the treatment gap between regions remain unresolved challenges.

The key task for the new Director-General will be to restore the organization's status as an independent norm-setting body, free from the political pressure of major donors and the influence of private capital. Concerns have been steadily raised that the autonomy of programs is being compromised as a significant portion of the organization's budget relies on specified voluntary contributions. Mahler's commitment to prioritizing primary care for vulnerable populations and defending health equity against commercial interests provides a benchmark for redefining the public role within a commercialized healthcare ecosystem.