California’s New Single-Payer Proposal Embraces Some Costly Old Ways

Three of the dirtiest words in health care are “fee for service.”

For years, U.S. officials have sought to move Medicare away from paying doctors and hospitals for each task they perform, a costly approach that rewards the quantity of care over quality. State Medicaid programs and private insurers are pursuing similar changes.

Yet the $400 billion single-payer proposal that’s advancing in the California legislature would restore fee-for-service to its once-dominant perch in California.

A state Senate analysis released last week warned that fee-for-service and other provisions in the legislation would “strongly limit the state’s ability to control costs.” Cost containment will be key in persuading lawmakers and the public to support the increased taxes that would be necessary to finance this ambitious, universal health care system for 39 million Californians.

Several health experts expressed skepticism about the bill’s prospects in its current form.

“Single-payer has its pros and cons, but if it’s built on the foundation of fee-for-service it will be a disaster,” said Stephen Shortell, dean emeritus of the School of Public Health at the University of California-Berkeley. “It would be a huge step backwards in delivering health care.”

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Paul Ginsburg, a health economist and professor at the University of Southern California, agreed and said the legislation reads like something out of the 1960s in terms of how it wants to reimburse providers.

“There’s broad consensus we ought to go from volume to value. This bill ignores all the signs pointing to progress and advocates a system that failed,” he said.

Backers of the Healthy California proposal are pushing for a vote in the Senate by Friday so the legislation can go to the state Assembly and remain in play for this year’s session.

The authors say that their single-payer proposal won’t rely entirely on old-fashioned fee-for-service and that there’s plenty of time for the bill to be amended. According to the authors, some of the criticism in the legislative analysis reflects a misreading of the bill: It would, they say, include some use of managed care.

In managed care organizations such as HMOs, providers receive a lump sum every month based on how many people they have enrolled. The idea is to encourage providers to offer preventive care and to scrutinize every test or treatment, since they bear the losses if they go over budget.

More than other states, California embraced this approach. In its Medicaid program, about 80 percent of enrollees are in managed care.

Michael Lighty, director of public policy for the California Nurses Association/National Nurses United, the lead sponsor of the California bill said “it will be a mixed-payment approach. Per capita payments are envisioned in this system.”

“We want to address how different payment methodologies work before mandating specifics in the bill,” he added.

Lighty said more provisions to curtail costs will be added shortly.

As opposition builds over congressional efforts to dismantle the Affordable Care Act, progressives in California and New York have responded to the ACA repeal threat by crafting proposals for universal coverage. (Such efforts failed earlier in Vermont and Colorado.)

Single-payer supporters are tapping into Americans’ deep dissatisfaction with the high costs and red tape embedded in the current hodgepodge of private insurance and public programs. But some defenders of the existing national health law say single-payer proposals are a costly distraction from the immediate fight in Washington over the health care safety net that millions of Americans rely on.

The California legislation, Senate Bill 562, requires that payments to providers be made on a “fee-for-service basis unless and until another payment methodology is established by the [Healthy California] board,” according to the bill.

It says health care delivery systems can choose to be paid on a capitated basis. But the analysis by the state Senate Appropriations Committee said it may be difficult for the single-payer program to establish such a payment system because of other features in the law, such as patients’ ability to see any provider with no referral necessary. A report in April from the state Senate Health Committee made a similar determination, saying multiple provisions in this bill “would make cost control unlikely to occur.”

The bill doesn’t address other innovative approaches being rolled out across California and the country. For instance, Medicare and private insurers are shifting to “bundled payments” for knee and hip surgeries, in which providers are paid a set fee for all treatment. More physician groups and hospitals are forming accountable care organizations (ACOs), which try to coordinate care within a budget.

While fee-for-service medicine can lead to excessive spending, Lighty said, ACOs and other “pay-for-performance” initiatives haven’t been entirely effective at reining in costs either.

The California bill faces another daunting challenge: coming up with the estimated $400 billion annually required to pay for universal coverage. Existing government money used for health care could cover half of that amount, but the other half may need to come from payroll taxes on workers and employers — not a politically palatable prospect. (The taxes could be offset in some measure by reduced health spending by employers and workers.)

Every Californian, regardless of age, employment or immigration status, would be eligible for coverage and there would be no premiums, copayments or deductibles. In addition, patients could see any willing provider without a referral and receive any service deemed medically appropriate.

Those factors would make it difficult for the program to use “drug formularies, prior authorization requirements or other utilization management tools,” the Senate analysts wrote. As a result, they estimated that health care utilization may increase by 10 percent compared to fee-for-service in Medi-Cal, the state’s Medicaid program.

At a hearing May 22, state Sen. Jim Nielsen (R-Tehama) said the single-payer proposal appears to invite patients to “come in for what’s almost like a blank check.”

State Sen. Ricardo Lara (D-Bell Gardens), a chief sponsor of the bill, acknowledged the concern and said he’s looking at what single-payer systems outside the U.S. do to contain costs.

The bill’s sponsors are opposed to the proliferation of narrow insurance networks that exclude providers to keep costs down. But the Senate analysis said that approach means the state couldn’t use potential exclusion from the single-payer system as a means of negotiating favorable prices, as health insurers often do.

Lighty said significant costs can be pared from the current system in other ways. For instance, consumers will no longer subsidize lavish salaries for hospital CEOs and excessive profits because reimbursements will be tied to “efficiently providing health care services.”

Lara said eliminating the middleman role of health insurers and consolidating the state’s purchasing power would lead to huge savings. “By pooling health care funds in a publicly run fund, we get the bargaining power of the seventh-largest economy in the world,” he said.

Insurers and brokers in California and nationwide oppose single-payer proposals because they could literally put them out of business. And legislative analysts and health policy experts question whether California would be able to exert sufficient bargaining power. They noted the political constraints that Medicare has faced in flexing its market power on prices.

“Our system of government may mean single-payer is much less successful than in other countries,” Ginsburg said. “We are so open to lobbying it means we can’t count on some of the very strong actions other countries have taken to keep costs down.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Cost and Quality, Repeal And Replace Watch, The Health Law

Tags: Legislation

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GOP Health Bill Pleases Most Republicans, But Not Many Other Americans

The health overhaul bill passed by the House earlier this month accomplishes one major feat: It is even less popular than the not-very-popular Affordable Care Act it would largely replace, a new poll finds.

According to the monthly tracking poll from the Kaiser Family Foundation, 49 percent of respondents said they have a favorable view of the ACA, while 31 percent said they favored the GOP’s American Health Care Act, which narrowly passed the House on May 4. (Kaiser Health News is an editorially independent program of the foundation.)

But in a mirror image of the ACA’s standing with the public, more than two-thirds of Republicans said they support their party’s health plan. Even more Democrats (78 percent) favored Obamacare.

The findings track those of other polls conducted since the Republican House passed the bill. A Quinnipiac University poll released May 25 found 20 percent of Americans support the AHCA, compared with 57 percent opposition. A poll from Morning Consult and Politico just after the bill passed found 38 percent supported the GOP measure and 44 percent opposed it.

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Unlikely to boost the bill’s popularity is a report last week from the Congressional Budget Office that found after 10 years the legislation would result in 23 million fewer Americans with insurance and could make it harder for those with preexisting conditions to get and keep coverage.

Indeed, the KFF poll found that even Republicans show scant support for a change to some of the health law’s most popular provisions. Fewer than a fifth of Republicans favored changing the provision that limits how much more insurers can charge older people for insurance compared with younger people. And 22 percent of Republicans favored letting insurers charge sick people higher premiums if they have a break in their coverage.

A majority of Republicans supported the bill’s provisions that would allow states to establish work requirements for Medicaid enrollees and set up high-risk insurance pools for people with health problems.

More people said the GOP bill would hurt their personal health care than thought the same about a straight repeal of the ACA when asked about that issue in December.

Forty-five percent said the GOP bill would increase their own and their family’s costs for health care, compared with the December survey that found 28 percent thought that would be the result if the ACA were repealed. More than a third thought the GOP bill would make it harder to get and keep health insurance, compared with 21 percent who thought a repeal would have that consequence. And 34 percent said the GOP bill would likely make the quality of their health care worse, compared with 19 percent who said that about the ACA repeal.

Although about half of the public wants changes in the bill, nearly three-quarters of those surveyed said it was very or somewhat likely that Congress will pass and President Donald Trump will sign a bill to “repeal and replace” the ACA.

The survey of 1,205 adults, conducted May 16-22, has a margin of error of plus or minus 3 percentage points for the full sample.

Categories: Insurance, Repeal And Replace Watch, The Health Law

Tags: Legislation, U.S. Congress

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Include tobacco in your spring cleaning!

This year include tobacco in your annual spring cleaning, and haul away those cigarette butts for good! Why? Because tobacco use is the second leading cause of death worldwide, responsible for 1 in every 10 adult deaths. If you or someone you love is ready, Medicare can help you quit smoking.

Medicare Part B covers up to 8 face-to-face counseling sessions in a 12-month period when you get them from a qualified doctor or other qualified health care provider. You pay nothing for these sessions if your doctor or other health care provider accepts assignment.

Bring out the trash bags and brooms—and make May 31, World “No Tobacco” Day, your day for a clean start.

Visit the Centers for Disease Control and the National Cancer Institute to learn more about how you can quit smoking. You can also watch our video to learn more about how Medicare can help you kick the smoking habit.

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Handshake-Free Zone: Keep Those Hands — And Germs — To Yourself In The Hospital

Dr. Mark Sklansky, a self-described germaphobe, can’t stop thinking about how quickly those little microbes can spread.

“If I am at a computer terminal or using a phone or opening a door, I know my hands are now contaminated, and I need to be careful and I need to wash my hands,” said Sklansky, professor of pediatrics at the David Geffen School of Medicine at UCLA.

Not all health workers are so careful, despite strict hand-washing policies in virtually all medical facilities. A 2010 study published in the journal Infection Control & Hospital Epidemiology showed that only about 40 percent of doctors and other health care providers complied with hand hygiene rules in hospitals.

Sklansky decided to test a new method at UCLA for limiting the spread of germs and reducing the transmission of disease: a handshake-free zone.

“We are trying to do everything to minimize hospital-acquired infection except for the most obvious and easiest thing to do in my opinion, which is to stop shaking hands,” he said.

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Hospital-acquired infections are a serious and potentially life-threatening problem in hospitals, and the unwashed hands of health care workers are often to blame. On any given day, 1 in 25 patients across the U.S. suffers from at least one infection acquired while they are in the hospital, according to the federal Centers for Disease Control and Prevention.

Sklansky first proposed the concept of handshake-free zones in a 2014 editorial published in the Journal of the American Medical Association. His proposal launched a debate about the possible risks of the time-honored greeting.

In 2015, Sklansky decided to try out the idea with a six-month experiment. He picked a place where patients are especially vulnerable — the neonatal intensive care unit. Infections among infants can cause them pain, prolong their stay in NICU, require more medications and even put them at risk of dying.

The anti-handshake experiment took place at two of UCLA’s NICUs, in Westwood and Santa Monica. Starting in 2015, Sklansky and his colleagues explained to the staff and families the purpose of handshake-free zones and posted signs designating the new zones. The signs feature two hands gripping each other inside a circle with a blue line through it, and the words: “To help reduce the spread of germs, our NICU is now a handshake-free zone. Please find other ways to greet each other.”

Instead of a handshake, non-contact greetings like a bow, a wave, or a smile are encouraged. (Courtesy of UCLA Health)

They didn’t ban handshakes outright. They suggested other options: a fist bump. A smile. A bow. A wave. A non-contact Namaste gesture.

“We aren’t like a military operation,” Sklansky said. “We are just trying to limit the use of handshakes.”

This spring, Sklansky and his colleagues published the findings of a survey on their handshake-free zone experiment in the American Journal of Infection Control. They found that establishing such zones is possible, can reduce the frequency of handshakes and that most health care workers supported the idea. They didn’t measure whether avoiding handshakes actually reduced the rate of infections, but Sklansky said he hopes to answer that question in a future study.

Though the formal experiment is now over, the signs in the NICUs are still in place and doctors and nurses still discourage handshakes.

Avoiding handshakes is an effective way to decrease the spread of germs, said Maureen Shawn Kennedy, editor-in-chief of the American Journal of Nursing. Health care providers do wash their hands frequently, she said, but often they don’t do it for long enough or use the right technique. And bacteria live on computers, phones, medical charts and uniforms throughout hospitals, she noted.

“There are just so many reasons to avoid handshakes, even when people are washing their hands,” Kennedy said. “Just because someone is walking around in a white coat … doesn’t mean they don’t have bacteria on their hands.”

Although there is no data to prove that reducing handshakes limits hospital infections, one study showed that bumping fists was more hygienic than shaking hands.

However, some infectious-disease specialists believe health care workers don’t need to stop shaking hands. They just need to scrub better.

In a 2015 editorial in the Texas Heart Institute Journal, Herbert Fred, a Houston physician, wrote that “the problem isn’t the handshake: it’s the hand-shaker.” Doctors need to ensure their hands are clean before touching patients, he said.

Didier Pittet, an international expert on hand hygiene, said in an email that handshake-free zones are not the solution for hospital-acquired infections. They simply “reflect the lack of capacity in infection prevention and control,” he said.

Sklansky agreed that hospitals need to improve compliance with hand hygiene, and he said handshake-free zones aren’t designed to replace hand-washing but to complement it. “I actually think handshake-free zones will bring attention to the hands as vectors for disease and help improve compliance with hand hygiene,” he said.

Neonatologist Joanna Parga, who was part of UCLA’s handshake-free survey, said she liked the idea when she first heard about it but wasn’t convinced it would work. Shaking hands is “so ingrained in our culture,” and it is how many doctors connect with patients, she said.

Neonatologist Joanna Parga, pediatric cardiologist Mark Sklansky and nurse Anahit Sarin-Gulian talk about the handshake-free zone while standing in the neonatal intensive care unit at Ronald Reagan UCLA Medical Center. They discouraged handshakes and suggested other options: a fist bump, a bow, a smile. The goal was to reduce the spread of germs and the transmission of infection. (Anna Gorman/KHN)

Parga said she has tried several alternatives to shaking hands, including bowing, making eye contact and touching people on the shoulder. She believes some of the other options are more intimate than a handshake — and they open up a conversation about safety. “Especially in a fragile patient population like the NICU, we really need to think about how we can protect our patients,” she said.

On a recent afternoon, as Parga walked through the Westwood NICU, she introduced herself to a mother who was holding her infant son.

“Hi. I’m Dr. Parga,” she said. “Are you Mom? I’m not gonna shake your hand. … It’s to help prevent infection in the NICU.”

Meena Garg, a neonatologist who is the medical director of the NICU in Westwood, said she still finds not shaking hands uncomfortable sometimes, because patients often extend their hands in greeting. “You feel like you are being rude,” she said.

But Garg said she supports the handshake-free zone, because it is an easy — and inexpensive — way to reduce infections. “I am the medical director so I have to look at costs,” she said. “This doesn’t cost anything, but it may be just as important as anything else we do.”

As part of the UCLA survey, Sklansky and his colleagues asked staff and parents what they thought of the new handshake-free zones.

The majority of health care workers supported the idea — especially medical school students and nurses. Male doctors were the most resistant to giving up the handshake, partly because they weren’t convinced it was necessary to prevent infections.

Families, however, were universally supportive of the handshake-free zone, Sklansky found.

New mom Brittney Scott said she’d never heard of a handshake-free zone and wasn’t sure about the idea. “But once you really understand the meaning behind it, it’s great,” she said. (Anna Gorman/KHN)

On one recent day in the NICU, Brittney Scott stood beside the crib of her 2-week-old son, Samuel, as he slept. He had ended up there with intestinal problems.

Scott said she’d never heard of a handshake-free zone and had instinctively offered her hand to a doctor when she first arrived. She said she was “a little taken aback at first” when the doctor declined to take her hand. “But once you really understand the meaning behind it, it’s great.”

Scott knows Samuel is at risk of infection, so avoiding germs is critical. She said she now prefers a smile to a handshake.

“A smile goes a long way in here,” she said. “There’s a lot of ups and downs … being a parent to a NICU baby.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Categories: Public Health

Tags: Children’s Health, Hospitals

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Drug Rebates Reward Industry Players — And Often Hurt Patients

Medicare and its beneficiaries aren’t the winners in the behind-the-scenes rebate game played by drugmakers, health insurers and pharmacy benefit managers, according to a paper published Tuesday in JAMA Internal Medicine.

The paper, which dives into the complex and opaque world of Medicare drug price negotiations, finds that rebates may actually drive up the amount Medicare and its beneficiaries pay for drugs — especially for increasingly common high-priced drugs — and it offers some systemic solutions.

“How these rebates and price concessions happen between the manufacturer of the drug and the PBMs [pharmacy benefit managers] and health plans can directly impact patient cost in a big way,” said the paper’s lead author, Stacie Dusetzina of the University of North Carolina-Chapel Hill’s pharmacy school.

The paper’s findings and proposed solutions come as President Donald Trump’s administration, Congress and state lawmakers grapple with ways to control drug prices and overall health spending. Trump’s administration has said it wants to lower drug prices and hinted at mandating rebates in Medicare. Leaders on Capitol Hill have called for Medicare price negotiations.

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In the JAMA paper, Dusetzina cites the EpiPen as one example. Last year, executives at Mylan, the maker of the EpiPen, said the list price of the drug for life-threatening allergic reactions was $600, but the company earned $274 after rebates and other fees.

That savings, though, isn’t necessarily passed on to patients in Medicare’s system. Instead, the money tends to be swallowed up by health insurers and middlemen like pharmacy benefit managers.

And, even though patients don’t pay list prices for their drugs, those high prices (like $600 for the EpiPen) are used to calculate how much Medicare covers for any individual patient — and sometimes what patients pay out-of-pocket, Dusetzina said.

“We’ve heard over the years that the list price doesn’t really matter, that it’s not the real price,” Dusetzina said. “It matters.”

The way it matters is not easily apparent. Here’s what happens: When a Medicare patient picks up a prescription, what they pay toward it is generally based on that higher list price and not the price after rebates, so the amount the beneficiary pays is scaled upward as a result.

And Medicare uses that high-end list price to calculate how rapidly beneficiaries reach the dreaded doughnut hole, where patients pay a bigger share of the price of the drug after their spending hits $3,700, the 2017 benchmark. Once through the doughnut hole, Medicare picks up the bulk of the drug’s cost.

High list prices drive patients into and out of the doughnut hole faster, raising their out-of-pocket costs and Medicare expenditures.

Dusetzina and co-authors Rena Conti, assistant professor of health policy and economics at the University of Chicago, and Dr. Peter Bach, director of Memorial Sloan Kettering Cancer Center’s Center for Health Policy and Outcomes, propose solutions to this problem.

Bach called the current Medicare system “absolutely devastating for people on high-cost specialty drugs.”

Bach’s drug pricing lab at Memorial Sloan Kettering offers an interactive tool for comparing how dollars shift when using the list price and post-rebate price.

The authors recommend that patients should be charged flat-dollar copays rather than coinsurance charges, which are based on a percentage of the drug’s price. The copays could be tiered, depending on the cost of the drug, the paper suggested.

This solution comes, in part, because the number of Medicare enrollees paying coinsurance for their drug, rather than a flat fee, has increased to 58 percent last year from 35 percent in 2014, the paper notes.

Another tactic would be to address the underlying disconnect between rebate negotiations and savings for Medicare and beneficiaries. The authors suggest that incentives for health insurers need to change to require health plans to pay more of the drugs’ costs after beneficiaries pass through the doughnut hole.

In addition, Dusetzina said, using the post-rebate amount in Medicare’s calculations would allow Medicare beneficiaries to move through the doughnut hole more slowly. That would save both patients and Medicare money.

“It really just stops us from accelerating people through the benefit,” Dusetzina said.

Last month, the Pharmaceutical Research and Manufacturers of America, which represents the pharmaceutical and biotechnology industry, launched a “Share the Savings” advertising campaign calling for public education about how the savings from rebates don’t actually get passed on to commercial insurance patients.

In an email, PhRMA’s Holly Campbell said the group’s commissioned research has found that rebates and discounts have nearly doubled from 2013 to 2015. Campbell said PhRMA believes “insurance companies should share more of the rebates and discounts they receive with patients.”

America’s Health Insurance Plans, which represents the insurance industry, calls the assertion that rebates and other discounts aren’t passed along “absolutely inaccurate” and noted the “true issue” is that drug prices continue to skyrocket “with no clear explanation as to how prices are set.” Insurers pass the savings from rebates on in different ways, including lower monthly premiums and co-pays, said AHIP’s Cathryn Donaldson.

Dusetzina said there is one caveat to the Medicare study: It is unclear how many drugs get a rebate and for how much because there is lack of transparency when it comes to rebates.

The paper’s final suggestion is about transparency. It says that federal regulators should require rebate data to be reported for individual drugs and then use that information to change Medicare’s benefit design in a way that “would lead to savings” for Medicare and its enrollees.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Categories: Cost and Quality, Health Industry, Medicare, Pharmaceuticals

Tags: Drug Costs, Prescription Drugs

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Ban on foreign funds for non-profit may hurt India health programs

By Aditya Kalra

India’s ban on foreign funding for the Public Health Foundation of India (PHFI), a non-profit group backed by the Bill & Melinda Gates Foundation, may damage some government health programs, according to the group and a health ministry official.

In a letter to the health ministry dated May 3, the non-profit said many of its programs linked to the ministry were in “suspended animation” and that its domestic funds would only help it run operations until June.

Affected programs included those on eliminating black fever, HIV prevention, tobacco control and universal health coverage, PHFI wrote in the letter, which was reviewed by Reuters.

PHFI activities such as training health workers for government programs and research into non-communicable diseases could be hurt by the funding ban, said Soumya Swaminathan, secretary of the department of health research in the federal health ministry.

“They are important partners. They have several important projects on the ground with states,” Swaminathan told Reuters.

Since Narendra Modi was elected prime minister in May 2014, India has canceled the foreign funding licenses of more than 9,000 foreign-funded non-governmental organizations (NGOs) and sacked dozens of government consultants who were paid by global aid agencies.

Some of Modi’s Hindu nationalist supporters have targeted PHFI and other groups they say favor foreign companies and act against India’s interests.

The cancellation of PHFI’s license on April 10 is significant because it supports several federal and state health departments and counts senior government officials among its members, unlike most charities which have no government links.

The PHFI has filed a request with the government for reinstatement of its license.

Swaminathan, who is a member of some PHFI committees in her capacity as a ministry official, said the health secretary had written to Modi’s office, giving details about what the PHFI provides to the health system.

Modi’s office did not respond to Reuters queries.

Foreign funding licenses allow organizations working in India to receive donations from abroad. Without one, a group like PHFI, which receives about 65 percent of its money from foreign sources, would struggle to stay afloat.

About a third of the roughly $30 million foreign contributions PHFI received in 2015-16 came from the Gates Foundation, according to a document seen by Reuters.

An India spokeswoman for the foundation, which was founded by Microsoft founder Bill Gates and his wife Melinda, said that it works with federal and state governments “on their request, on projects aligned with their priorities”.


In cancelling PHFI’s license, the federal home ministry said the group had engaged in “diversion of funds” and not declared certain foreign receipts. Such violations, the ministry said, were “detrimental to public interest”.

It also said the group used foreign contributions to “lobby” media, parliamentarians and government on policy aimed at controlling tobacco consumption. Those attempts to influence, the government said, violated India’s foreign funding rules.

The PHFI denied it had lobbied anyone but said it did take part in information campaigns on the dangers of tobacco use on the instructions of the health ministry.

All PHFI activities were “fully aligned to national health goals and serve (the) national interest,” said PHFI head K. Srinath Reddy, who is also a professor at the Harvard School of Public Health and former president of the World Heart Federation.

Pradeep Haldar, an official in the health ministry, told Reuters on Monday that an essential immunization unit funded by the Gates Foundation that had been managed by PHFI will now be run by Boston-based public health group John Snow Inc.

The unit provides strategy and monitoring support for the government’s immunization program, which is one of the world’s largest, reaching 26 million infants each year.

PHFI said it would work with the health ministry to ensure a smooth transition, which has to be achieved by June 1. Haldar said the transition to John Snow will be “seamless”.

A source close to the Gates Foundation said John Snow will take time to adapt to the program and vaccination targets could suffer in the meantime.

There was no one available to comment in John Snow’s India office and the group did not respond to emails.


Swadeshi Jagran Manch, a nationalist group linked to Rashtriya Swayamsevak Sangh (RSS), the ideological parent of Modi’s party, has raised objections against the PHFI in the past.

A senior member of Swadeshi Jagran Manch, Ashwani Mahajan, said he told the health minister in March that the Gates Foundation and its partners like PHFI promoted policies that favoured foreign companies and were against national interests.

The Gates Foundation has in the past been accused of possible conflicts of interest in its association with India’s immunization program because it backs GAVI, a global vaccine alliance that includes the big multinational pharmaceutical companies.

“We don’t need you,” Mahajan told Reuters, calling on the Gates Foundation to not think of India as a “white man’s burden.”

It is unclear whether Mahajan’s intervention influenced the government’s decision.

Mahajan said his group would look into the new John Snow arrangement.

“We’d like to study the credentials of the new partner, the government should be more cautious,” he said.

Asked about the possible health impacts of PHFI’s license cancellation, Mahajan said: “In all ways, our country is self-reliant.”

(Reporting by Aditya Kalra; Editing by Douglas Busvine and Sonya Hepinstall)

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