Open letter to the Stop TB Partnership on the need to strengthen its role in the struggle against TB
11 October 2011
Professor Rifat Atun
Chair, Coordinating Board
Stop
TB Partnership
c/o World Health Organization
20 Avenue
Appia
1211 Geneva, Switzerland
Re: Strengthening the role of the Stop TB Partnership in
the struggle against tuberculosis
Dear Professor Atun,
We are writing to follow up on our letter of May 3, 2011,
regarding the steps being taken by the Coordinating Board to
reduce the conflict of interest in the Stop TB Partnership’s
relationship with the World Health Organization (WHO), improve
transparency and accountability in the operations and activities
of the Partnership, and strengthen the Partnership’s ability to
fulfill its mandate.
In your response of May 16, 2011, you informed us that a
Sub-committee on Governance, Performance and Finance had been
formed, and would address some of our concerns. You also
informed us that the Department for Partnerships and the Legal
Unit of the WHO were developing a standard set of documents,
aimed at ensuring a uniform approach in the hosting arrangements
for all partnerships.
As you are undoubtedly aware, in their resolution on
partnerships the World Health Assembly (WHA) endorsed a very
specific new policy on formal partnerships that requires, among
other things, “that the function of the (partnership)
secretariat be, and be seen as, part of the functions of WHO.”
(Section 13). This is a fairly radical redefinition that will
have implications far beyond the Stop TB Partnership, and
directly affects the autonomy and function of what were meant to
be inclusive and innovative bodies. From what we have been told,
the WHO has begun internal discussions on guidelines and
operating procedures to implement this new policy and is
drafting agreements to be negotiated and signed with the
governing bodies of the hosted partnerships.
The new WHA resolution, and the measures through which it
will be implemented, raise fresh concerns about the autonomy and
potential effectiveness of the Stop TB Partnership, and of other
partnerships currently hosted by the WHO. In that regard, we
would be grateful if you would please update us on developments
that have taken place since May in the work of the Sub-committee
on Governance, Performance and Finance. In particular, we would
like to know if you or members of the Sub-committee are
currently examining proposals from the WHO on how the
organization intends to implementation the new WHA resolution.
If so, we would be grateful to know whether the Sub-committee
will be reporting to the Stop TB Coordinating Board on this
matter at the upcoming meeting in November. If negotiations with
the WHO do not result in an agreement conducive to the mandate
of the partnership and its ability to achieve its full
potential, what alternative hosting arrangements and contingency
plans have been considered? As this is a significant matter
affecting the effectiveness of the Stop TB Partnership, we hope
that the Coordinating Board will consider it carefully and
solicit views of Stop TB Partnership member organizations in
considering the different options.
It would also be helpful to know whether you or other
Sub-committee members have consulted with the leadership of
other WHO-hosted partnerships—such as UNITAID or Roll Back
Malaria—to understand how they intend to respond to the
resolution and the WHO proposals for implementing it. Some
meaningful degree of autonomy and transparency will likely be
important for the effectiveness of all hosted partnerships, and
it would be very useful to understand how they intend to fulfill
their mandates under the proposed regulations and procedures.
Many people are concerned about the state of affairs in
global tuberculosis control. On July 2, 2011, the Lancet called
for “a new era for global tuberculosis control,” stating that “a
status quo in tuberculosis control is unacceptable.”[1] This
public expression of concern is one that should be taken quite
seriously. To us, part of the challenge in the struggle against
tuberculosis has been an inability to leverage the skill-sets of
global partners to work effectively together. Although the Stop
TB Partnership was created to serve precisely this function, we
think that one of the reasons it has not happened is that the
Partnership has not had the independence and freedom to work
effectively and to complement the significant normative and
policy roles that WHO has played in the field.
While we support a strong and active WHO, we have become
increasingly concerned that the Stop TB Partnership has been
used to strengthen the WHO’s Tuberculosis Department at the
expense of strengthening the other technical and implementation
partners and of building synergies across health and development
programs. Moreover, it has happened through a system that lacks
accountability and transparency. For example, we were
disappointed to discover at the Stop TB Partnership Coordinating
Board meeting in March 2011 that a significant proportion of
Stop TB Partnership funds were being transferred to the WHO,
with little—less than 30 percent—going to support the activities
of other Stop TB partners. We worry that this type of imbalance
diminishes the ability of the Partnership to really engage
effectively with this unprecedented global alliance of
organizations committed to stopping the spread of
tuberculosis.[2] Clearly, the Coordinating Board was sensitive
to this issue as well, and has created the Sub-Committee to
which you referred in your letter.
The decisions about the allocation of resources are only
one area where the ability of the Stop TB Partnership to achieve
its full potential has been hindered. Currently, there is no
tendering process for the non-administrative activities of the
Partnership nor are there any rigorous performance indicators
for the Partnership’s activities. We were heartened at the March
meeting that Coordinating Board members expressed surprise at
serious problems that were highlighted about specific Stop TB
Partnership activities—concerning the function of the
USAID-funded TB TEAM and the activities of the Global Drug
Facility (GDF), for example—that have a direct impact on the
Partnership’s effectiveness in the struggle against
tuberculosis. These programs have been running for a number of
years, yet members of the Board indicated that the Board was not
made aware of serious, recurrent problems which are only now
being addressed. This revealed a lack of transparency and
deficiencies in reporting to the Board, as well as providing
support for the Coordinating Board’s interest in having stronger
governance and oversight roles.
From our analysis, it is clear to us that part of the
solution to these problems lies in the Stop TB Partnership being
given more independence and autonomy from the WHO’s own
Tuberculosis Department, while retaining a strong linkage with
the WHO as a whole. If this is done in an amicable way—and
coupled to a strengthening of the roles and responsibilities of
the Stop TB Partnership Coordinating Board and the Executive
Secretary—it will lay the foundation for a more coherent,
transparent, and effective structure to manage overall efforts
in the struggle against tuberculosis.
By acting as the host institution for the Stop TB
Partnership, the WHO has a fiduciary responsibility to act at
all times in the sole interest of the Partnership in matters
relating to administration of the Partnership. It is an accepted
element of law that a fiduciary must not profit from a fiduciary
position, include any benefits or profits that arise from an
opportunity afforded by the fiduciary position.[3] In fact, by
acting as host, the WHO assumes a greater ethical responsibility
for ensuring that the partnership works in the most transparent
way possible. The Coordinating Board also has a responsibility
to ensure good governance and that the interests of the
Partnership and its unique and important mission are not
compromised.
It is clear to us that members of the international donor
community are also concerned about accountability and governance
of global health partnerships. In a report published by the
United Kingdom’s Department for International Development (DFID)
on global health partnerships,[4] the authors recommend that
DFID “support a process to identify additional rules and
regulations which could be modified to provide greater
flexibility for WHO-hosted partnerships….”
In addition to recommending that DFID include transparency among
its criteria for engaging with global health partnerships, the
report called on DFID to encourage and support efforts, such as
establishing standing committees aimed at reviewing and
engineering appropriate governance structures. It argued that,
“Whatever the location of the secretariat, there should be a
clear delineation of how the Secretariat is to account to the
partnership governing body, and transparency in the exercise of
that accountability.” Regarding the Stop TB Partnership/Global
Drug Facility in particular, the DFID study quotes a McKinsey
report (2003) saying that, “an administrative arrangement that
offers more flexible staffing and legal support, greater
transparency, and a partnership-oriented attitude is now
necessary.”
In order to address the serious governance issues,
potential conflicts of interest, and barriers to the optimal
functioning of the Partnership, we are recommending that the
Coordinating Board include the following in any memorandum of
understanding between the WHO and the Stop TB Partnership:
1. Affirmation of the role of the Stop TB Partnership
Coordinating Board in the governance of the partnership, an
affirmation of the Partnership’s mandate, and recognition of its
operational independence and distinct role.
2. Placement (administratively) of the Stop TB Partnership
Secretariat under the Director General’s or Deputy Director
General’s office, or delegated to the Assistant Director General
for General Management. The Executive Secretary should not
report to the Director of the WHO’s Tuberculosis Department or
the Assistant Director General for the HIV-TB-Malaria cluster,
whether for administrative purposes—including the allocation of
funds or activities—or for annual evaluations. This would remedy
the manifest conflict of interest in the current governance
arrangement by ensuring that there is an arm’s length between
any disease cluster or WHO disease-related department that may
directly benefit from Stop TB Partnership funding or activities,
or through WHO’s administration of the Partnership.
3. Placement of responsibility for providing overall
management and leadership to the Partnership Secretariat in the
hands of the Executive Secretary. This means responsibility for
the administration, direction and guidance of the Partnership’s
work, and the provision of advice to the Board in setting
policies and developing strategies for the Partnership. As part
of this role, the Executive Secretary should be directly
responsible for establishing an organizational structure and
staffing plan to meet the goals and objectives of the
Partnership, in consultation with the Board, including the
responsibility for overseeing the implementation of the
Partnership Secretariat’s work plan and budget. The duties of
the Partnership Secretariat staff should be determined by the
Executive Director, working with the Board.
4. Delegation to the Executive Secretary to authorize the
use of Stop TB Partnership funds at the same level as an
Assistant Director General.
5. Delegation of authority to the Executive Secretary by
the Director-General of the WHO, and in accordance with the
WHO’s rules, that will permit her to exercise the functions of
the position. This would include representing the Partnership to
Ministries of Health in countries, and with directors at other
organizations.
6. Allocation of all non-administrative Stop TB
Partnership activities through a tendering process, with
published requests for application (RFAs), and clear performance
indicators. Contracts (APWs) should be created between the Stop
TB Partnership and all organizations receiving funds (including
the WHO’s Tuberculosis Department).
7. Strengthening of the Stop TB Partnership Coordinating
Board’s mandate for oversight and responsibility over Stop TB
Partnership operations. The Board should be reconfigured to
include a wider array of Stop TB Partners, with less permanent
seats. This will ensure regular turn-over and encourage
increased transparency and oversight.
8. Creation of a permanent Performance and Evaluation
Sub-committee that oversees the activities and outcomes of all
Stop TB Partnership activities.
Making sure that people infected with tuberculosis are
cured of their disease is of utmost importance to us. The
independence of the Stop TB Partnership and its ability to
fulfill its mandate will help in achieving this goal. The
current state of affairs—a lack of autonomy, accountability, and
transparency, coupled to problematic governance structures, and
mission confusion—will undermine tuberculosis funding in general
and support for both the Stop TB Partnership and the WHO.
The WHA resolution seems to provide important space for the
Coordinating Board to negotiate an agreement that would allow
for a vigorous and autonomous partnership (clauses 8i and 8j).
But this would require a much more active and engaged
Coordinating Board negotiating to ensure the effectiveness of
the partnership under revised hosting arrangements. We believe
that this is worth the effort because it could lay a sound
foundation for fulfilling the Partnership’s mandate and really
moving forward in the struggle against tuberculosis.
We would like to work closely and constructively with you
on these matters, and hope that you will take the time to meet
with us to discuss this further, and consider allowing a
representative of our group to present these concerns to the
Coordinating Board at their next meeting in Bangkok, Thailand.
Sincerely,
Mr. Jonathan Berger
Senior Researcher and Director of
Policy and Research
SECTION27, South Africa
Mr. Patrick Bertrand
Director
Global Health
Advocates, France
Ms. Lucy Chesire
Executive Director
TB ACTION
Group, Kenya
Ms. Michaela Clayton
Director
AIDS & Rights
Alliance for Southern Africa (ARASA), Namibia
Mr. Ted Constan
Chief Operating Officer
Partners
In Health
Professor Paul Farmer
Kolokotrones University
Professor
Harvard University
Mr. Nathan Geffen
Treasurer
Treatment Action
Campaign (TAC), South Africa
Mr. Gregg Gonsalves
Vice-Chair, Board of Directors
International
Treatment Preparedness Coalition
Mr. Loon Gangte
President
Delhi Network of
People Living with HIV/AIDS, India
Mr. Mark Harrington
Executive Director
Treatment
Action Group
Ms. Yetunde Ipinmoye
Policy and Advocacy Officer
Positive
Action for Treatment Access (PATA), Nigeria
Dr. Salmaan Keshavjee
Director, Program in Infectious
Disease and Social Change
Department of Global Health and
Social Medicine
Harvard Medical School
Ms. Alessandra Nilo
Director
Gestos – HIV+,
Comunicação e Gênero, Brazil
Ms. Morolake Odetoyinbo
Chair, Board of Directors
International
Treatment Preparedness Coalition
Mr. Shiba Phurailatpam
Regional Coordinator and
Director
Asia Pacific Network of People Living with
HIV/AIDS
Mr. Gregory Vergus
Regional Coordinator
ITPCru
EECA
Dr. Sarah Zaidi
Executive Director
International
Treatment Preparedness Coalition
Cc: Dr. Margaret Chan, Director-General, World Health
Organization, Switzerland
Dr. Lucica Ditiu, Executive Secretary, Stop TB Partnership,
Switzerland
Mr. Sandeep Ahuja, Operation ASHA, India
Dr.
Nils Billo, International Union Against Tuberculosis and Lung
Disease, France
Dr. William Bishai, Working Group on New TB
Drugs, USA
Dr. Amy Bloom, United States Agency for
International Development, USA
Ms. Nichola Cadge,
Department for International Development, United Kingdom
Dr.
Ken Castro, United States Centers for Disease Control and
Prevention, USA
Dr. Jeremiah Muhwa Chakaya, DOTS Expansion
Working Group, Kenya
Dr. Paul De Lay, UNAIDS,
Switzerland
Dr. Marja Esveld , Ministry of Foreign Affairs,
The Netherlands
Dr. Peter Gondrie, KNCV Tuberculosis
Foundation, The Netherlands
Mr. Michel Greco, Working Group
on New TB Vaccines, France
Dr. Christy Hanson, United
States Agency for International Development, USA
Dr. Diane
Havlir, TB/HIV Working Group, USA
Dr. Nobukatsu Ishikawa,
Research Institute of TB, Japan
Dr. Aamir Khan, Working
Group on MDR-TB, Pakistan
Dr. Michael Kimerling, Gates
Foundation, USA
Mrs. Blessina A. Kumar Vice-Chair Stop TB
Partnership Coordinating Board, India
Honorable S.E. Mr.
Abdallah Abdillahi Miguil, Ministry of Health, Djibouti
Professor
David H. Mwakyusa, Ministry for Health and Social Welfare,
Tanzania
Professor Kyaw Myint, Ministry of Health,
Myanmar
Ms. Carol Nawina Nyirenda, CITAM+, Zambia
Ms.
Sarah Nicholls, Canadian International Development Agency
(CIDA), Canada
Dr. Rick O'Brien, Global Laboratory
Initiative Working Group, Switzerland
Dr, Madhukar Pai,
Working Group on New TB Diagnostics, Canada
Honorable Dr.
Mphu Keneiloe Ramatlapeng, Ministry of Health, Lesotho
Ms.
Montserrat Meiro-Lorenzo, World Bank, USA
Honorable Dr.
Meliton Arce Rodriguez, Ministry of Health, Peru
Honorable
Dr. Aaron Motsoaledi
Ministry of Health, South Africa
Dr.
Masato Mugitani, Ministry of Health Labour and Welfare, Japan
Dr.
Mario Raviglione, World Health Organization, Switzerland
Dr.
Giorgio Roscigno, Working Group on New TB Diagnostics,
Switzerland
Dr. Herbert Schilthuis, Heineken International,
The Netherlands
Dr. Mel Spigelman, Working Group on New TB
Drugs, USA
Dr. Tonka Varleva, Ministry of Health,
Bulgaria
Dr. Hao Yang, Department of Disease Control and
Prevention, China
Dr. Jorge Bermudez, Executive Secretary,
UNITAID, Switzerland
Dr. Marine Buissonnière, Open Society
Institute, USA
Ms. Joanne Carter, RESULTS, USA
Professor
Awa Marie Coll-Seck, Executive Director, Roll Back Malaria,
Switzerland
Dr. Philippe Duneton, Deputy Executive
Secretary, UNITAID, Switzerland
Dr. Myriam Henkens,
Médecins Sans Frontières, Belgium
Ms. Brigitte Laude,
Director, Administration and Finance, UNITAID, Switzerland
Dr.
Hirohito Nakatani, World Health Organization, Switzerland
Mr.
Thomas Teuscher, Roll Back Malaria, Switzerland
Dr. Francis
Varaine, Médecins Sans Frontières, France
Dr. Tido von
Schoen-Angerer, Médecins Sans Frontières, Switzerland
Mr.
Paul Zintl, Harvard Medical School, USA
[1] A new era for global tuberculosis control? The Lancet 2 July
2011 (Volume 378 Issue 9785 Page 2).
[2] The WHO has
defended these kinds of allocations as consistent with donor
requests or instructions from the secretariat of the Partnership
itself. The current institutional arrangements between the WHO’s
Tuberculosis Department and the Stop TB Partnership made these
decisions a foregone conclusion. Not only does the Executive
Secretary of the Partnership report to the Director of the WHO’s
Tuberculosis Department for finalization of work plans,
allocation of Stop TB Partnership resources, and annual
performance reviews, but both of them sit on the five-member
Executive Committee of the Coordinating Board of the
Partnership.
[3] In Seminole Nation v. United States, 316 U.S. 286, 296-297 fn. 12 (1942), the Supreme Court of the United States has stated: “Many forms of conduct permissible in a workaday world for those acting at arm's length are forbidden to those bound by fiduciary ties…. Not honesty alone, but the punctilio of an honor the most sensitive, is then the standard of behavior. As to this there has developed a tradition that is unbending and inveterate. Uncompromising rigidity has been the attitude of courts of equity when petitioned to undermine the rule of undivided loyalty by the `disintegrating erosion' of particular exceptions. . . . Only thus has the level of conduct for fiduciaries been kept at a level higher than that trodden by the crowd.” See: Conaglen, M. (2005) The Nature and Function of Fiduciary Loyalty. Law Quarterly Review 121: 452 - 480. Weinrib EJ. (1975) The Fiduciary Obligation. University of Toronto Law Journal 25(1): 1-22. Mary Blasko, Curt Crossley & David Lloyd, Standing to Sue in the Charitable Sector, 28 U.S.F. L. REV. 37, 59 (1993). See also the following examples of case law: Keech v Sanford [1558-1774] All ER Rep 230; Meinhard v Salmon, 1928, 164 NE 545 at 546; ASIC v Citigroup [2007] 62 ACSR 427 at 289.
[4] DFID Health Resource Centre. GHP Study Paper 5: Global
Health Partnerships increasing their impact by improved
governance. Author: Kent Buse.
Accessible on line at:
http://www2.ohchr.org/english/issues/development/docs/WHO_5.pdf
