At AAccountability we use an accountability framework that borrows heavily from the WHO’s “Multisectoral Accountability Framework to End Tuberculosis”. We have done this because it’s an excellent framework, and has helped a large number of governments and health services improve their accountability. It’s also helped the global public health community see where this isn’t happening. While there is always room for improvement in any initiative - especially anything related to accountability - we think it’s one of the most important yet under-appreciated developments in global public health in a long time and we’re excited to see the difference it’s making in the real world.
One of the truisms of power is that power has an uneasy relationship with accountability. This makes it a useful exercise to examine how the countries of the world came together to establish such a helpful set of accountability commitments for TB: as a neglected issue, maintaining the status quo is often the easiest outcome. There are multiple reasons new accountability was established, but right at the centre of them is the idea that if you don’t ask, you don’t get.
First, some context. The global fight against tuberculosis, the world’s second-deadliest infectious disease (after Covid) that kills more than four thousand people every day, is not going well and has not gone well for a very long time. Thanks to the world’s commitments to fighting infectious diseases, first in the Millennium Development Goals (2000-2015) and then in the Sustainable Development Goals (2016-2030), bold and ambitious commitments to TB were made and agreed by all countries of the world.
That looks great on paper and TB’s global goals have always been achievable in theory. But in practice, has TB never had the political attention or funding it would take to achieve them. In September 2023, for example, the annual gap in TB funding was still $5.8 billion per year just for programmes in lower- and middle-income countries alone - less than half of what was needed.
As we moved from the MDG to SDG era, the TB community was getting sick of it: Sick of hearing great promises followed by wholly insufficient action from the leaders making these promises. We needed better accountability.
Probably the most important step in securing greater accountability was securing a UN High-Level Meeting (HLM) on Tuberculosis to be held in September 2018. These meetings are called for by the United Nations General Assembly, and every Head of State or Government is invited to attend - this is the “high-level” part of the name. HLMs are relatively uncommon: TB was the deadliest infectious disease in the world and the advocacy community was making increased noise at all levels, making TB increasingly impossible to ignore.
While pushing hard with advocacy to secure an HLM, the TB community planned for success and spent considerable time and energy debating and agreeing what ‘key asks’ they had for world leaders. Having the outcomes they wanted agreed early amongst TB advocates and stakeholders made it much, much easier to collectively push for them at every stage of the process.
This mattered: High-Level Meetings that don’t have good political leadership can produce political declarations that are vague, lack specificity, and have no mechanisms in place for checking back in - no monitoring, no review. Having heard it all before, the TB advocacy community was not prepared to let another global moment go by and be a platform for nice words and big promises without some kind of mechanism for accountability to the promises made.
So, accountability became one of the five key asks from the TB community for the 2018 HLM.
But it wasn’t just civil society and communities that pushed for better accountability. The World Health Organisation played a pivotal role in developing what would ultimately become the Multisectoral Accountability Framework to End TB. The core mandate for this work was asked for and given by the World Health Assembly at its 71st meeting in March 2018, even though the work had begun back in 2017 and the WHO’s Global TB Programme had been spending considerable time promoting increased accountability directly with health ministers and ministries.
This commitment from the World Health Assembly was critical in lending weight and legitimacy to the calls for greater accountability coming from civil society - an almost textbook case of the whole being greater than the sum of the parts. These efforts came together in the High Level Meeting’s final Political Declaration with the final six paragraphs - and entire page of text - laying out the accountability actions that countries were committing to.
The momentum this gave to accountability mechanisms, including the WHO’s Multisectoral Accountability Framework to End Tuberculosis, was invaluable. We have seen in country after country how this has been incredibly helpful in securing more and better outcomes in the fight against TB.
To be clear, the 2018 HLM didn’t deliver all the accountability mechanisms that TB needs: meaningful global review is still absent, and much of the accountability language is directed at countries with high TB burdens rather than at countries with available ODA financing and where much health research and development is based. The latest results from the 2023 Global TB Report make for uncomfortable reading given how far off track we still are from the commitments made in 2018. The weakness of accountability in the political declaration from the recently completed 2023 HLM shows backsliding that is unconscionable given how badly the Covid crisis has set back the fight against TB specifically. So work remains to be done.
What lessons can we take from the world of TB for application elsewhere? Given the thoughtful, structured, and above all implemented and helpful framework coming out of the 2018 processes, advocates for any SDG issue could learn from the TB community’s experiences using a high-level political moment to improve accountability. These lessons can be applied whether we have a specific UN HLM or not, but we certainly can’t miss the opportunities that already exist. For example, in September of 2024, the UN is having a Summit of the Future: advocates should be demanding accountability for what will undoubtedly be a moment where world leaders, yet again, make lovely-sounding promises. Without that accountability, we risk missing, yet again, an opportunity to drive real change and see SDG promises fulfilled.