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Three of the most important global public-health jobs are up for grabs this fall. How these leadership positions are filled will help determine the world's strategy for confronting health threats ranging from AIDS to pandemic flu for years to come.

The United Nations' World Health Organization is preparing to elect a new director-general following the unexpected death in May of its former chief, Lee Jong Wook, of a stroke. Nominations for the job are due today. The Global Fund to Fight AIDS, Tuberculosis and Malaria is interviewing applicants to fill its top post, succeeding Richard Feachem, who will step down as executive director in January after more than four years on the job. And the World Bank has a search under way for a new senior vice president for its human-development network, who will oversee its health programs, following the retirement of the incumbent this past July.

The unprecedented number of simultaneous openings comes at an unnerving time. Global health crises are mounting -- from the march of avian flu to increasing resistance to critical drugs to the continued inability to stem the death toll from AIDS.

At the same time, the emergence of influential private organizations like the Bill & Melinda Gates Foundation, growing involvement in health by groups like the World Bank, and solo government programs like Pepfar -- President Bush's AIDS relief program -- have shifted the balance of power in public health. That has raised questions about the role of agencies like the WHO. With an annual budget of about $1.66 billion, the U.N. agency is constrained financially. It also has no regulatory power, so it can't force member countries to adopt or adhere to its policies.

"People complain that WHO is getting marginalized," says Kelley Lee, a global health governance expert at the London School of Hygiene & Tropical Medicine. But, she says, "WHO needs to be a coordinating body -- no other organization could fulfill that role."

The new leaders have the opportunity to reshape the public-health landscape. As the U.N.'s public-health agency, the WHO now sets policies and standards for health care in 192 member countries and coordinates global public-health responses to outbreaks. The Global Fund, created in 2002 by the U.N., has committed $5.5 billion to finance programs in 132 countries. The World Bank devotes an average of $1.4 billion annually in loans and credits to health programs.

Veterans of the WHO and other public-health agencies have thrown their names into the hat for the WHO director-general slot. Their campaigns are already in full swing, and a new chief is expected to be chosen in a special election Nov. 9. Candidates include Margaret Chan, the WHO's top communicable-diseases official and a former health director in Hong Kong, whose experience combating avian flu and severe acute respiratory syndrome, or SARS, makes her a formidable candidate; Shigeru Omi, the WHO's regional director for the Western Pacific, also credited for his experience in battling avian flu and SARS; Julio Frenk, Mexico's health minister, credited with reforms to bring health coverage to his country's millions of uninsured; Pekka Puska, a Finnish expert in strategies to prevent heart disease and other chronic conditions; and Tomris Turmen, a Turkish pediatrician and expert in family and community health at the WHO. (WHO officials who are running have taken leaves of absence from the agency.)

The choice for WHO chief is steeped in U.N. politics. The decision is made through rounds of voting by secret ballot that frequently involve horse-trading between countries, as officials trade nonhealth-related favors for support of one candidate or another, say agency veterans. "There is a political give and take which often means the very best doesn't get through," says Derek Yach, director of the Rockefeller Foundation's global health program in New York and a former top WHO official.

In contrast, the search for a new Global Fund executive director resembles hunts for new corporate CEOs. The London-based search firm Odgers Ray & Berndtson collected 334 applications for the position. The search firm and a nomination committee created by the fund's board drew up a list of 18 top candidates, and the board nomination committee is scheduled to discuss in a telephone meeting today which candidates it will interview in person later this month.

Officials who have applied for the job include Arata Kochi, the WHO's malaria chief, who is on an aggressive campaign to overhaul the agency's prevention and treatment strategies, and Jacob Kumaresan, a former tuberculosis expert at WHO and president of the International Trachoma Initiative, a New York-based organization. Their status on the list isn't known.

While the World Bank has started searching for a new human-development chief, it's unclear when the position will be filled, according to a World Bank spokesman.

Despite the importance of the positions, the selection of leaders for both the WHO and the Global Fund are made behind closed doors. An article in The Lancet last week called the Global Fund's decision not to make the names of serious candidates public a "perplexing hypocrisy" and called for an open debate on the choice. Keeping the list secret "will prevent the public scrutiny necessary to ensure that the Fund accelerates its growth," the Lancet concluded. A Global Fund spokesman said the board's chair had read the Lancet article, and that the board would "weigh the different concerns" raised in the piece.

Filling the jobs with strong, visionary public-health leaders would create an opportunity to shape new strategies and find more efficient ways for the growing number of organizations involved in public health to coordinate their efforts, public-health experts say. The WHO in particular faces growing pressure to assert greater leadership over the new players. "There's a chance to make sure there are really strong, public-health-minded people with clear visions who understand that the world has changed dramatically and are able to interact with a complex set of players," says Dr. Yach. "The stakes are high, and there are real opportunities."

Complaints have grown among public-health experts that the WHO and other health organizations too frequently duplicate efforts or tread onto one another's turf. A push by the WHO into AIDS treatment with its so-called "3 by 5" program raised questions about whether the agency was stepping too far out of its main policy-setting mandate. The program failed to meet its goal of providing life-saving drugs to three million people in poor countries by the end of 2005. Critics have also called on the WHO to police global health programs more aggressively, ensuring that health groups employ the proper strategies and treatments.

The new Global Fund chief will face another set of challenges: persuading countries and organizations to contribute to the independent Geneva-based foundation despite donor fatigue. The fund needs someone who has strong managerial skills but is also a talented fund-raiser, public-health experts say. The organization is currently trying to raise money to fund a sixth round of grants. It says requests for funding from 97 countries total $5.8 billion over the next five years. It estimates its shortfall to fully fund the sixth round of approved grants at $500 million.