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Deciding When to Leave
The decision to close or hand over a medical program or leave a country for whatever reason is always based on an analysis of whether our presence and operations are still required and relevant.
Stable or unsafe situations
MSF will leave or close a program when a previously violent situation is sufficiently stable and displaced populations have safely been able to resettle in their native areas. On the other hand, teams may leave if it becomes necessary to denounce the diversion of aid away from the most vulnerable civilians (refugee camps in Zaire 1995 and DPRK 1998). Equally, a conflict situation can deteriorate to the point when MSF and other humanitarian staff are threatened or murdered (Somalia 1997, Iraq and Afghanistan 2004). While infrequent, this does happen and often results in the temporary or permanent withdrawal of our teams for their own safety. However, if an authority or armed/political group deliberately obstructs MSF’s access to operations in a specific area, MSF may use humanitarian positioning or public lobbying to try and reverse the situation.
Capacity and responsibility
Leaving will be considered when local or national authorities and local actors have the capacity and motivation to restore and develop a medical system able to meet the needs of the population. If there are other actors, humanitarian or otherwise, providing medical support, MSF teams will also assess whether their presence brings a risk of effort being duplicated.
A decrease in acute needs
MSF will leave when our presence interferes with local activities and capacities. MSF will end an intervention when a medical emergency, such as a meningitis or measles epidemic or natural disaster, ceases to exist. In these cases, relief operations are eventually replaced by longer-term development activities by other actors (which was seen eventually after the Asia tsunami). Teams will also move on when marginalized populations, such as prisoners and street children, are no longer excluded from healthcare.
Of course, the decision to stop, close, handover a program or leave comes with no guarantee that MSF will not need to return in future (such as with Sri Lanka when MSF left in 2003 but had to return in 2006 when the conflict escalated again). There is no guarantee that a conflict will not resume, that medical and humanitarian needs will be correctly addressed or will not again reach a medical crisis-point or that the resources and strategies put in place will not be diverted and misused.
The decision to bring an end to assistance is, therefore, based on our experience, our perception of the situation and our concern that our short-term solution should not wrongly substitute more permanent solutions. It is an acknowledgment that our actions and presence are limited and replaceable. MSF does not represent a long-term response to the public health responsibilities of a State but contributes to strategic healthcare improvements by training national teams before leaving.
While it can appear a significant decision to make, ending activities reflects the will and identity of MSF to carry out its specific mandate as an emergency medical-humanitarian actor that exists to help the most vulnerable people at times of extreme crisis.