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Perceptions of MSF- Based on Experiences of an Emergency Relief Worker in the FieldLinda Ethangatta Who Knows What and Who MSF Is at the Field Level? Generally speaking, the majority of my professional colleagues in humanitarian work regard MSF’s professional humanitarian service very positively. The reasons for MSF’s renown among peers are many and sometimes depend on the section of MSF as well as the nature of actual program or project in a set area of service delivery (emergency response, nutrition, water, and sanitation, etc.). Overall, based on my more than 15 years of experience working in emergency, as well as experience in more sustainable country programs, I believe MSF should be congratulated. At the same time, it is important to raise several questions and concerns about the organization and about humanitarian work in general. Is MSF Visible in the Project Area Where It Performs Its Interventions? In terms of humanitarian interventions it is useful to know who does what and in which geographic area. This helps avoid overlap in service delivery and informs beneficiaries where they should go to receive services. MSF brings a high level of resources in health and related interventions. However, MSF has an unwillingness to present a national (or regional) visibility in areas where it provides service. By standards of national governments, MSF does not feature anywhere in the national arena when identifying partners in a majority of interventions. However, to local partners and other players at the regional and subnational level, MSF is well known in the immediate geographical area of coverage. MSF is well known by partners as an agency of “endless potential to support the needy in a crisis.” For example, MSF usually provides essential drugs kits at health units at the grassroots level, making it possible to meet the needs of the most vulnerable members of a community. Again, in the majority of developing countries, essential medical kits and surgical and lab equipment are hard to come by, and that is why MSF support is well appreciated. MSF is also respected for sharing protocols and technical guidelines, utilizing its technical know-how to develop and share up-to-date information. Partners on the ground appreciate this generosity and make use of these materials for training and technical updates. It has never been clear to us professionals working at the grass-roots level why MSF likes to keep such a low profile, especially among national leaders, when providing these noble services. MSF as a Poor Communicator: More Communication and Social Marketing Are Required to Educate the Community on the Health Interventions Covered in Project Areas Communication about projects at different levels can lead to better use of MSF services. MSF often seems none too keen to let partners or communities know why they choose to undertake a particular intervention. Perhaps MSF uses appropriate data analysis to select a particular country, region, or district for interventions. However, most partners on the ground in areas of operation just find MSF setting up an operation. This lack of communication has led to cases of overlap in services and some resentment. For example, there was a section of MSF setting up a feeding center in a remote geographic region which another NGO claimed to be their area of coverage. There had been no communication at all from MSF even though the other NGO had a feeding center not far from where MSF chose to establish its center. Does MSF Consider the Importance of Building Local Groups’ Capacity in Anticipation of Handing Over a Project at the End of a Funding Period? Partners on the ground observe that MSF sections do not always consider this aspect of all projects. As a professional colleague from another humanitarian agency, I have seen some projects abandoned with no continuation after the exit of MSF. The closing of centers that provide needed relief—leaving no continuity—is not positively received by professional teams or communities. It seems that at times there is no exit strategy for MSF. MSF could train local staff to continue after exit. This can be achieved through partnership with local actors. It could also be possible if temporary facilities are built within established centers instead of stand-alone buildings, especially for the non-emergency health conditions like kala azar and tuberculosis (TB). In some of these health interventions (TB, HIV/AIDS, kala azar) the host communities suffer for many years without assistance from the local administration. When MSF comes to support the community everyone is most grateful. It’s tragic if MSF leaves without planning a proper exit strategy for a sustained approach that addresses the health condition in the future. MSF often works in complex situations in which there is more than one partner on the ground. In these complex emergency situations MSF is seen as a champion because of its ability to provide most essentials (drugs, logistics, personnel, even airlifts for the critically injured). In these situations local staff are essential to help reduce the burden of work and fatigue. I have personally seen MSF international workers become “burnt out” because they work very long hours and under tremendous stress. The question then is: “Is there no policy within MSF to train, coach, and mentor locals, who are in many ways already trained health personnel, to support the international staff?” This is one component of MSF work that I found unacceptable, especially in emergency situations. Why Send Professionals Who Are Highly Skilled in One Area of Medical Work Into Remote Conditions Where a Broad Range of Health Needs Are Observed Among Many Patients? Many MSF professionals present great skill in their area of specialization. Doctors are strictly doctors, so are the nurses. In some cases nurses come out into the rural areas straight from ICU experiences in Europe. These professionals are ill-prepared to work in remote villages with no electricity, and are also prone to infections like malaria. When presented with real medical crises, such as a patient suffering from acute malaria, the doctor is not even able to diagnose the condition. It is important to screen the appropriateness of skills a volunteer has and deploy them to the field only after a sound analysis of the role they can play in service delivery. In similar—though indirect—situations I have observed a failure to meet minimum operational standards like those found in the “Sphere Guidelines.” In such cases MSF staff members who have no knowledge of a particular intervention are given the authority to take charge. Without a basic understanding of the phenomena, the correct application of protocols and guidelines is impossible. In one field situation, I witnessed an MSF section not following the criteria for admission into a therapeutic feeding program for the severely malnourished children. This led to a situation where mothers with very sick and severely malnourished children were made to stay at home and access the service as outpatients. This is why I am saying that MSF did not ensure that properly skilled staff members were matched to this intervention. The perception from others is that sometimes the guidelines are not observed because the MSF section wants to be seen in the context of numbers of people reached or geographic area covered. This means spreading interventions too thinly to have a sustainable impact. This has been interpreted by partners on the ground as a “political” attempt by MSF to be perceived as an agency that is able to reach a large number of people and to be seen as a leader among humanitarian agencies. Why Does MSF Perpetually Rely on Short-Term Field Staff? It is common knowledge in the field that MSF has an extremely high staff turnover. This is unfortunate both for professionals and the organization. A staff working for only three months has very little time to learn and apply knowledge. This is critical, especially in the context of doctors or experts who may leave a project just at the point that they have begun to understand the medical problem they are handling. It may be useful for MSF to review this policy and identify a better approach to personnel management. A Sign of Courage For many years I regarded MSF sections as very courageous. MSF was quick to get very close to combat zones to treat the injured. I saw this firsthand in southern Sudan. MSF sections were able to operate in the most remote areas and in so doing were really appreciated by all, especially the agencies who had limited logistical support. As years went by and MSF became targets in conflict zones, it became evident that MSF was just as vulnerable as other agencies and therefore needs to exercise caution to protect staff. 
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