From February 28, the National Technical Advisory Group on Immunisation will be delinked from the Immunisation Technical Support Unit funded by the Bill and Melinda Gates Foundation. The unit provides what the government calls “techno-managerial” support to its Universal Immunisation Programme, one of the world’s largest schemes to protect children from vaccine-preventable diseases.
The advisory group will be moved to the National Institute of Health and Family Welfare, a government-funded autonomous organisation that works as a think tank for health and family welfare programmes in the country. Until now, the advisory group’s meetings were held at the Immunisation Technical Support Unit, which is located in the Delhi office of the Public Health Foundation of India – a public-private initiative set up in 2006 with funding from the government and the Gates Foundation.
On Wednesday, the Economic Times reported that all financial ties between the National Technical Advisory Group on Immunisation and the Gates Foundation had been cut, and that the former would now be fully funded by the government. The report referred to “conflict of interest issues” in the relationship between the advisory body and the Gates Foundation, which were allegedly raised by members of the steering group of the National Health Mission and the Swadeshi Jagran Manch, a Rashtriya Swayamsevak Sangh affiliate that looks at economic issues. It also had health activists expressing concern over the Gates Foundation’s influence on the country’s immunisation programme as a result of its ties with pharmaceutical companies.
The Ministry of Health and Family Welfare clarified later in the day that there are no financial links between the advisory group and the Gates Foundation or any other organisation, since the former body consists of independent experts. The Gates Foundation will continue to support the Universal Immunisation Programme beyond February 28 and the transitioning of the National Technical Advisory Group on Immunisation secretariat, it said. “BMGF [Bill and Melinda Gates Foundation] continues to collaborate and support the Ministry of Health and Family Welfare,” a ministry statement read.
It called moving the secretariat out of the Gates Foundation-funded institute “planned activity” and “part of the health system strengthening efforts by the government”. It added that the “contours of the support” to the immunisation programme are being finalised with the Public Health Foundation of India and the Gates Foundation.
“Immunisation Technical Support Unit for NTAGI was only working as a secretariat,” said Dr Pradeep Haldar, who handles the Universal Immunisation Programme. “They only give notices to doctors, follow it up with the committee members, help with powerpoint presentation, record minutes.”
Despite shifting the National Technical Advisory Group on Immunisation out of its building, the Immunisation Technical Support Unit will continue to function as before, the ministry said, implying that it would still provide technical support to the government but not host the advisory group’s meetings.
Who sets immunisation agenda?
In 2012, the health ministry signed a memorandum of understanding with the Gates Foundation to “augment efforts” to achieve universal immunisation. The Gates Foundation, along with the Public Health Foundation of India, established the Immunisation Technical Support Unit. The unit suggested potential pathways for achieving comprehensive coverage of immunisation services, with special focus on difficult and hard-to-reach places and populations. With its establishment, the National Technical Advisory Group on Immunisation was moved out of Nirman Bhawan, where the health ministry is situated, and into the unit’s office.
The advisory group consists of independent experts who provide recommendations on vaccines after reviewing data on disease burden (the impact of a health problem measured by financial cost, mortality, morbidity or other indicators) and efficacy and cost effectiveness of the vaccines. Its members include experts such as Dr Jacob Puliyel, a paediatrician with St Stephen’s Hospital in Delhi, and Dr NK Arora from the International Clinical Epidemiology Network, among others.
“When the main agenda of the committee is vaccines, how could the technical support be given outside the government?” asked Dr Yogesh Jain, who runs the non-profit Jan Swasthya Sahyog and is part of the National Health Mission’s steering group.
There have been allegations that the advisory group’s meetings were controlled by the Immunisation Technical Support Unit. In an article in the Sunday Guardian in March, Puliyel questioned moving the advisory group out of Nirman Bhawan, asking why the health ministry could not pay the salaries of 32 people in the secretariat itself. “ITSU now puts together the papers supporting vaccines and it decides the agenda of the NTAGI and also controls what is recorded as minutes of the meetings,” he wrote.
Puliyel alleged that the Immunisation Technical Support Unit recorded the decisions of the committee based on votes and not arguments presented against a vaccine. He added that opposition against the pentavalent vaccine, which protects against diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenzae, were not recorded in the minutes, which are a crucial public record.
Pradeep Haldar, who handles the Universal Immunisation Programme, denied these allegations and said a maximum of two staff members dealt with the secretarial functions. “Setting the agenda for meetings is out of question,” he said.
The Gates Foundation has also denied any role in policy-making. “The Foundation does not play any role on policy decision-making pertaining to immunisation, which is a sole prerogative of the Government of India,” a spokesperson said.
Links with drug firms
The questions that have been raised over the role of the Gates Foundation in the country’s immunisation programme are largely because of its links to the Global Alliance of Vaccines and Immunisation, or Gavi, which counts big pharmaceutical companies among its partners. The Gates Foundation provided the initial funding to set up Gavi in 2000 and continues to contribute towards its running with other funders such as the United States government.
Gavi has provided vaccines for some immunisation campaigns such as for the pentavalent vaccine and the measles-rubella vaccine introduced in the Universal Immunisation Programme, said Haldar. “Gavi, through Unicef, has supported us with grants that were not loans,” he said. “They have also provided commodity assistance – meaning providing of the vaccines.” He added that Gavi contributed less than 1% of total funds for the immunisation programme.
However, activists like Amar Jesani, who is a part of the National Health Mission steering group, feel that even this association amounts to a conflict of interest. They have raised questions about whether Gavi vaccines are the best vaccines for India’s immunisation strategies. Jesani pointed out that the government has not been able to provide evidence of vaccine effectiveness or cost-benefit analyses of vaccines provided by Gavi and used in the programme. “The vaccine programme is introduced with an assurance from Gavi that they will make it available for a few years,” he said. “What happens when the donor support is withdrawn? We need projections for the time when the government has to buy it from the market.”
In 2014, a senior bureaucrat with the health ministry, Anuradha Gupta, joined Gavi, giving rise to more questions of conflict of interest.
The influence of the donor is all pervasive, alleged Jesani. “Removing NTAGI from the [ITSU] secretariat is not sufficient.”