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By: Joan Tallada
Consultant  

Quite often, when we refer to the term Conflict of Interest (CoI), it seems that we are talking about interests that are illegitimate, obscure or outlawed. Most of the times this is not the case. In fact, although the usual term we use is Conflict of Interest, in reality it would be more appropriate to call it Conflict of Interests, with the second noun in plural. Why? Simply because the situation occurs when two or more interests coexist in a person or entity, both likely legitimate but that conflict with each other. So the focus should be not that much which interests we are talking about, but whether they conflict with each other or not and how.  

Let me take the example of a person with cancer with a legitimate interest in controlling the availability of oncology drugs. The problem arises if that same person, in addition to having cancer, is, for example, a pharmacist hired by the public system as responsible for the distribution of said medications, or is a direct relative of the pharmacist, or the person with cancer is also the owner of a company that sells or distributes oncological drugs to the public sector. That person, in these situations, has two interests, both legitimate: their interest as a person with cancer and their pecuniary interest as a public system employee or as a family member of an employee or as a potential beneficiary of a public acquisition of medicines through the company they own. You have here at least two interests that conflict with each other: you have a Conflict of Interest.  

The same could be said of an organized group of neighbors, who have an interest in monitoring that the funds allocated to improvements in their neighborhood have been used correctly. If it turns out that it is also one of the entities that has received funds to, for example, manage a library, promote children’s activities or promote community health, then it has a second interest, the financial one. That is, the group, in this case, has at least two interests that conflict with each other: it has a Conflict of Interest. 

Deciding when two or more interests are in conflict is not always an easy job. There may be situations when that is crystal clear, as the ones described above, but other times nuances, thin lines and complex relationships may make declaring a conflict of interest challenging. Let’s take the Global Fund definition of Conflict of Interest, latest updated in 2020: 

“Covered Parties have a conflict of interest when by act or omission, a Covered Party’s Private Interests, or those of an associated person or associated institution, interfere¹ with the performance of his or her official power, role, duty or function with respect to a Covered Activity, or with the integrity, independence and impartiality required of this person’s role or position.  

(…) A conflict of interest may be actual, potential or perceived, defined as follows: 

• Actual conflict of interest. A conflict of interest that occurs when a Covered Party faces a real and existing conflict of interest. 

• Potential conflict of interest. A conflict of interest that occurs when a Covered Party is or could be in a situation that may result in a conflict of interest. 

• Perceived conflict of interest. A conflict of interest that occurs when a Covered Party is or could be in a situation that may appear, according to a reasonable neutral third-party observer, to be a conflict of interest, even if it is not an actual or potential conflict of interest.” 

Unambiguous Conflict of Interest have been faced by Country Coordinating Mechanisms (CCMs) where representatives of KPs and PLHIVs belonged to CSOs which also were – or expected to be- grant recipients. According to the Global Fund rules, CCM members should “recus[e] themselves from discussions, decisions, and voting where there is a conflict of interest, including decisions related to oversight and selecting or financing of implementers.” This has not always been the case, raising complaints from other members of the community, but fortunately more and more CCMs are taking action in order to avoid or mitigate to the maximum possible CoI among their members. 

In other cases, however, more complex interpretation is required to address questions such as: What do we mean by “interfere”? Who decides that, or which type of Conflict of Interest are we facing? Under which criteria?  

Conflict of Interest in Community-Led Monitoring (CLM) is a good example that answers are not always straightforward. Indeed, we all agree that CLM is a powerful tool to advocate for greater access to quality health services for Key Populations (KPs) and People Living with HIV (KPs). At first sight, it seems quite obvious that KP & HIV CSOs are the best candidates to implement CLM programs. But what happen when, as it is case in a good number of countries, the same CSOs are service providers? It would be natural that those CSO-led services are included as part of the CLM targets to assess their accessibility and quality. In that scenario, how can we address the Conflict of Interest, either actual, potential or perceived?  

In their document “Conflict of Interest in Community-led Monitoring programs” from 2022, the Community-Led Accountability Working Group (CLAW) provides some guidance to address Conflict of Interest in CLM:  

In situations where no CSOs other than those implementing services are good candidates to carry on CLM activities, CLAW recommends “to pause the CLM effort while [new] capacity is built”. Clear enough. But, always according to CLAW, when CSOs implementing services belong to a coalition, “the monitoring of its own services needs to be done by another member of the coalition in order to avoid COI.” I find that option problematic, because it ignores what we could name the crossed Conflict of Interest: the CSO in charge of the CLM is not implementing services but their coalition partners are, which may affect the CLM CSO independence, even not intentionally. Furthermore, a CSO carrying on CLM may not be providing services today but may want to do it in the future, a will that may affect their objectivity when they assess other CSOs services or even the public system services.  

Both the Global Fund (in a broader sense) and CLAW (more specifically in relation to CLM) offer measures to mitigate the COI and specify who, within the Global Fund Secretariat or the CCM, could be the authority to deal with it. In the same line, countries will greatly benefit from elaborating written COI policies that guide them to identify, manage and eventually resolve those conflicts for the benefit of the communities we all serve.  

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¹ The emphasis is mine.