News and Opinions  –  2018

71st WHA: tuberculosis multisectoral accountability framework - parallels with the antibiotic resistance debate

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In September this year, a high-level meeting on tuberculosis (TB) will take place during the UN General Assembly. In preparation for this meeting the World Health Assembly (WHA) will adopt a resolution which includes the proposal for a multisectoral accountability framework. There are parallels between the accountability framework and the antibiotic resistance debate, and could contain valuable lessons for the way forward on issues such as governance, accountability and monitoring for antibiotic resistance.

Pulmonary Tuberculosis: Chest x-ray show alveolar infiltration at both lung due to mycobacterium tuberculosis infection. Photo: Shutterstock.

UNGA high-level meeting on tuberculosis

Despite tuberculosis (TB) have had a longer history of being considered a global health crisis, and the policy discussion has had time to mature more than the global policy discussions on antibiotic resistance, TB is only now  being raised to the UNGA level, two years after antimicrobial resistance  was placed there for discussions.

Tuberculosis has therefore been prominently featured on the agenda of the 71st World Health Assembly which takes place in Geneva this week, in preparation for the high-level meeting on tuberculosis taking place at the United Nations General Assembly (UNGA) in September later this year. In response to a request from the WHO Executive Board, WHO has been working with key stakeholders to develop a tuberculosis multi-sectorial accountability framework. This was originally included in the Moscow declaration to End TB where WHO and Member States committed to develop such a framework.

Need to map out areas of accountability

There is an increasing need for a more systematic approach to accountability with an ever growing number of actors that contribute to the end TB strategy. The draft accountability framework aims to be accelerating the progress to end TB. Good governance and accountability requires that reporting mechanisms are put in place by countries to monitor progress and identify gaps in meeting requirements. Multilateral organizations, governments, and a strong civil society are all essential parts in governance and accountability.

Good governance, accountability, stakeholder participation and transparency are important enablers and part of the 2030 Agenda.

Framework elements proposed for tuberculosis

The draft tuberculosis multisectoral accountability framework covers the whole accountability process cycle, including: commitments, actions, monitoring & reporting and review. It provides non-exhaustive lists of elements for all components both at a global, regional and national level. It builds on what already is done for each of the components and make suggestions on additional needs to strengthen the accountability process cycle. The development of the draft accountability framework was inspired by existing accountability frameworks on other health issues, such as the Framework Convention on Tobacco Control.

For tuberculosis the main gaps identified was related to the review component. Therefore, the main element proposed to be added is periodic high-level review(s) of the tuberculosis response at global or regional level, and/or independent review. The review should take a multi-sectorial approach and engage key stakeholders, including civil society and tuberculosis-affected communities.

At a national level, several gaps were identified, and related to the components on actions, monitoring & elimination and reporting. As a result, the national level of the draft framework includes several proposals including a need to revise plans, policies and associated activities, based on recommendations that are coming from a high-level review. For the monitoring & reporting component, reporting of tuberculosis cases via national surveillance, and national tuberculosis reports are essential elements. High-level political review of the national TB response is also seen as a top priority for the national level.

Accountability framework on antibiotic resistance?

The parallel to what is happening on antibiotic resistance at global, regional and national levels – with all the initiatives and structures that are emerging – is evident. With an increasing number of actors and an emerging risk of incoherent policies, there is a need to ensure effective more transparency of actions to allow for monitoring for accountability of international organizations, government, private sector and industry. The antibiotic resistance global governance debate has only recently  been initiated for example within the UN IACG on AMR. However, this process but could benefit from incorporating an accountability framework at an early stage.

Rapid development of actors

To be of relevance for the antibiotic resistance field, an accountability framework would need to consider the rapid development in the number of actors engaging with antibiotic resistance. To be effective, it should be developed in a transparent and inclusive process. As in the case of tuberculosis, the review component of implementation of existing resolutions, policies and commitments may probably already be the weakest component in terms of accountability also for the field of AMR. Likely, this type of high-level review will be an important element to strengthening accountability on antibiotic resistance.

Stand alone or incorporated accountability framework?

Whether to have a stand alone accountability framework on antibiotic resistance, or to be incorporated into for example a legally binding UN convention or similar, should be further discussed. The draft WHO, FAO, OIE tripartite Monitoring & Evaluation (M&E) of the Global Action Plan on AMR, which is being developed, provide a structure and approach to the M&E. Taking into considerations the proposals of the TB accountability framework, the M&E of the Global Action Plan could be complemented with high-level reviews. By linking commitments, actions, monitoring & evaluation and review to a governance structure it will be clear who is accountable for what.What approach the IACG on AMR will take to ensure coherence with this ongoing work is still unclear, as their report on future global governance and accountability is yet to be published for public consultations.

Proactive discussion needed

It would be of value to have a proactive discussion on what elements of a multi-sectoral accountability framework for antibiotic resistance that already exists and what might be missing. To have clear commitments, actions, monitoring & reporting and review mechanisms in place at an early stage will likely accelerate the progress to effectively manage the challenge of antibiotic resistance.