Management Sciences for Health (MSH), a private nonprofit organization that works to strengthen health systems worldwide, was founded in 1971 by Dr. Ronald O'Connor, who wanted to provide technical assistance in public health management to the developing world.
MSH is based in Cambridge, Mass., and receives the vast majority of its funding from the federal government — $155,826,790 for fiscal 2005. MSH is involved in multiple health policy and service areas, including leadership development, financial management, pharmaceutical procurement and inventory management.
Partly as a result of its international work in treatment and supply chain management, MSH is one of the largest recipients of President's Emergency Plan for AIDS Relief (PEPFAR) grants over the last three years, receiving more than $44 million in fiscal 2005 alone. MSH has been receiving funding from the U.S. Agency for International Development (USAID) for 35 years, said Dr. Malcolm Bryant, MSH's director for the Center of Health Outcomes.
In September 2005, the Partnership for Supply Chain Management (PSCM), a nonprofit group created by John Snow Inc. and Management Sciences for Health, was awarded a USAID contract that totals up to $7 billion. The contract was for providing pharmaceuticals and related supplies in PEPFAR countries. MSH and JSI are joined by 15 subcontractors, which include universities, defense companies and international health organizations.
MSH's role in PSCM is multifaceted. It assists in the coordination of country support for HIV/AIDS commodity policy; provides training, guidance, management and technical expertise as well as quality insurance.
MSH has previous experience in supply chain systems and has a program called Rational Pharmaceutical Management Plus Cooperative Agreement, which predates PEPFAR. The program aims to improve access to drugs, vaccines, supplies and equipment.
Critics of PSCM point out that it would be much more efficient to dedicate money and resources to strengthening existing systems and using locally based organizations rather than create a duplicate system that applies what they call a "cookie-cutter" approach and that may not be sustainable in the long term.
Relationship with the U.S. government
Despite MSH's close relationship with USAID, it has sometimes spoken out against proposed U.S. government health policies. In February 2003, MSH was one of many groups that signed an open Human Rights Watch letter to President Bush opposing a proposed extension to HIV/AIDS funding of the "global gag rule," or "Mexico City" policy, which restricts U.S. funds from going to organizations that provide abortion services. MSH was concerned about the U.S. government's planned separation of reproductive health and HIV/AIDS services abroad, thereby disqualifying many organizations with integrated programs overseas from receiving HIV/AIDS funding.
MSH staff members have also been vocal about concerns from their in-country partners that their activities are being restricted. "PEPFAR is constraining. There is more that we could be doing," Bryant said. "Some of the restrictions … make it uncomfortable for us, and it certainly has limited us in working with partners in the field. There is a partner we work with in Rwanda, but on principle they refuse to allow themselves to be dictated to and simply will not engage" with PEPFAR.
Treatment as prevention
Yet, MSH also acknowledges the successes that PEPFAR funding has brought. One area in which PEPFAR has been widely recognized is in providing antiretroviral treatment to many more people around the world. The treatment has transformed HIV/AIDS from a fatal condition to a manageable illness.
General treatment of the virus itself is also considered to be a form of prevention. "Until universal treatment was an option, HIV was a death sentence," Bryant said. "As people enter the system, they will get counseling, and this greatly raises the chance that they will change their behavior."
In addition to funds for antiretroviral treatment, MSH receives funding for its work in several countries on Preventing Mother-to-Child Transmission of HIV (PMTCT). The most common method of PMTCT is through a single dose of Nevirapine to the mother during delivery and to the baby immediately following birth. PMTCT is one of the ways MSH is involved in PEPFAR's prevention work.
In response to a question, Bryant said he doesn't know if PMTCT programs could be cut back as a result of PEPFAR's earmarks for other prevention methods. There are no good studies that show that other prevention methods such as abstinence campaigns result in behavior change, he said, while "there is evidence that PMTCT prevents" HIV transmission. "There should be no mother that gives birth that shouldn't be able to see that child live and raise that child," he said.
An ICIJ reporter met one of the mothers MSH worked with in Addis Ababa, Ethiopia. Demeku Shenkute was five months pregnant with twins when she found out she was HIV-positive. Having experienced stigma and discrimination, Shenkute now keeps her status to herself.
Stigma is one of many issues that MSH has tried to address in its work overseas. By working with health managers in countries like Ethiopia to develop confidential settings where patients can be given medicines and privately counseled, MSH hopes to make the situations of Shenkute and the millions of others in similar positions more tolerable.
Marina Walker Guevara contributed to this story.