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