Themes From the Project Part 2
In Cameroon, MSF carried out a vertical project designed to fight a neglected disease called Buruli ulcer. It is not yet known how this disease is transmitted. In Akonolinga, patients receiving treatment for Buruli ulcer are now considered privileged. Indeed, the wing of the hospital where they are cared for has been renovated and these patients receive food rations in addition to their medicines. Previously, it was thought that patients suffering from Buruli ulcer had been punished for their sins (witchcraft, theft, rape, etc.). The disease played a social role in the community. In all discussions, even with MSF’s national staff, two types of “atom” were described: the “simple” type and the “mystical” type. The simple atom can be treated in MSF’s facilities, unlike the mystical one, which, despite the willingness of the clinicians, can only be treated by the traditional healer. There were also tensions between traditional healers and MSF due to the fact that the treatment provided by MSF is free of charge, while patients must pay to be treated by traditional practitioners. The other project in Cameroon was located in Yaoundé and looked after HIV/AIDS patients. Many informants made a distinction between “biological” AIDS and a “slow poisoning” of mystical origin.
This is a dimension that MSF has great difficulty grasping. In some cases, the teams bring in anthropologists to get an idea of the social components of the communities in which they are working, but then have difficulty adapting their operational strategies in light of the information obtained.
In Kyrgyzstan, secularism is historically linked to politics, and consequently influences how MSF is perceived. In this context, it can be important to present the organization as nondenominational rather than secular. Indeed, secularism was imposed by the communist regime, which banned religions. In contrast, French-style secularism separates the public sphere from the private sphere, with religion belonging to the second category.
It emerges from the study that the organization is not evolving in a vacuum, totally sealed-off from religion. The fact that MSF is a nondenominational organization does not guarantee that beneficiaries, partners, and so on will not view it through the prism of their own religious economy. MSF must first understand its place in a religious environment, then it will be able to position itself more appropriately and differentiate itself from religious organizations. This differentiation is not a goal in itself, but is essential in order to present a coherent message and a homogeneous identity to the outside world. Ultimately, the objective is to improve MSF’s access to vulnerable populations, which means that this debate also needs to be translated into operational objectives.
The Humanitarian Aid System
The international humanitarian aid system (headed by the UN agencies) and coordination between the various NGOs and local associations shape how foreign agencies are perceived. In some contexts, the image varies according to the country or region of origin of the humanitarian action. Local charitable traditions and local definitions of humanitarian action were another feature to be taken into account.
In its current form, humanitarian assistance is largely considered a “Western” product provided by “whites.” In Cameroon, the link between the “whites” and humanitarian aid is permanent. Aid is seen both as a guarantee of quality and as an obligation that “whites” have towards “blacks.” The landscape of humanitarian action is nevertheless evolving, as China, for example, is now cited as a development actor in the medical field.
In the case of emergency relief, as in Iraq, the results of the analyses confirm that there is no clear-cut distinction between the perception of humanitarian action and other types of intervention motivated by political, military, economic, or religious factors. Moreover, humanitarian organizations do not seem to be perceived as detached from the interests of their countries of origin and their actions are regarded as Western. An interest in finding natural resources in Iraq was often mentioned as an underlying reason for intervention.
In Kyrgyzstan, although humanitarian aid generally has a positive image and is considered useful, the motivations of individuals and of humanitarian action are often difficult to understand. It is interesting to note that for younger respondents, who have no memory of the USSR and its influence in the world, “humanitarian action” was mainly developed by Europeans. Older respondents suggested that humanitarian aid was like a “Trojan horse” for political activities. One employee recalled that, in the Soviet era, international cooperation did exist, particularly with African countries, but that its main objective was to fight capitalism in the world.
In Guatemala and Niger, a minority of respondents expressed concerns about the possible establishment of dependencies on humanitarian aid, which is perceived as taking responsibility away from the state and reducing the endogenous resources of the local populations. However, most civil society organizations stated that they value collaboration and proximity with international humanitarian NGOs. The fact that these organizations bring certain problems to light was also seen as a valuable form of support for national organizations, which can benefit from the fruits of their labor. Involvement with international NGOs could also force local organizations to adopt a position on issues they would otherwise have avoided addressing, such as violence against women. In a few rare cases, however, the representatives of civil society organizations fear that excessive focus on international organizations could undermine the position of national organizations and give the impression that they are acting as representatives of foreign interests.
For many people in Cameroon, as well as in Iraq, the concept of a “totally free” gift is difficult to grasp. The idea of free health care can arouse suspicion. For example, people are afraid that NGOs might be spying for foreign governments or military forces, or are conducting medical trials. Some respondents see links between humanitarian aid in general and a system of North-South domination.
The Kurdish population in Iraq is unfamiliar with MSF’s activities in its own country, but seems to have more information about its work in other parts of the world. The Iraqi impression that their country had lost its place on the international scene often emerged in interviews and many people were eager to complete medical training in order to regain that place: “One day I’ll be a doctor and I’d like to work for MSF because of my studies. Iraq was really well known for medical studies all over the world, and now we have to go to Jordan or Iran to get even the smallest operation.”
Perception Among Different Groups
Perceptions Among Patients
In general, the presence and medical treatment offered by MSF are appreciated by the beneficiary populations. The organization’s clinical management and approach to patients were described as very consistent and complete. In Cameroon, patients stressed the personal approach and psychological support that they received in addition to the medical treatment. In Niger, the relationship between patients and medical staff, the trust in the staff, and their ability to listen, were cited as being equally important as the quality of the treatment.
In some contexts, patients underlined the dual role of MSF’s presence in the region in terms of economics and political effect on medical programs. For example, in Kenya, patients felt the effects of MSF’s economic role when the head of the household received a treatment: “We need their services to raise our living standards . . . MSF has reduced our expenses because hospital bills are free of charge, so we don’t have to sell our animals.” Similarly, in Liberia, many people appreciated the free care while never questioning the quality of care provided. The project met their needs because it “helps us to survive.” In Kyrgyzstan, most patients said that their medical situation and living conditions had greatly improved since the start of the project. Furthermore, the presence of the organization and the care provided by it were perceived as very important in terms of respect for human dignity, a value they did not feel from the doctors working in the prison system. In Niger, MSF programs were said to have made people aware of the problem of malnutrition and the fact that they did not receive full information from the government.
Among the criteria for assessing MSF’s work, many of the people consulted mentioned the following: time spent on, and quality of, the services provided; relevance and appropriateness of the programs and services offered to patients in relation to their needs; transparency and clear communication about the financing, objectives, goals, and beneficiaries of the aid; improvement of patients’ health; distribution of aid; improvement of general quality of life for local populations; and basic health education provided by MSF. These factors improved trust in medical care. Local populations no longer view traditional healers as the only option for getting well. In Kenya, patients said that they were satisfied with the health education provided to the local populations. In Niger, health awareness campaigns, especially on the preparation of porridge to prevent malnutrition, made mothers feel that they were no longer passive recipients of aid.
For many patients in Niger and Liberia, geographical coverage was mentioned as a real problem, as they had to travel long distances to reach health centers. It would also seem that MSF did not communicate enough with patients regarding admission criteria or its reasons for setting up a given medical project. It is interesting to note that, in Kyrgyzstan, most prisoners, as well as the other respondents, thought that the main reason MSF was providing tuberculosis treatment in prisons was public health rather than individual rights to medical care. In addition, some prisoners thought that MSF’s treatments were clinical experiments.
An overview of feedback from patients in different contexts shows that people appreciate MSF’s presence, services, and impact on health programs, even though they were not always able to identify MSF, its principles, or its logo. Patients’ perceptions also demonstrate the need to improve the organization’s communication about its projects, the reasons for its intervention, the geographical areas where it is present, and the groups targeted by medical projects.
Perceptions Among Authorities
It is interesting to note that perspectives differ between well-educated urban respondents and people who use MSF medical facilities in isolated locations, which are often in rural areas a long way from an urban center. By way of example, the differences found in Niger are rather striking. While those (mainly women) frequenting the nutrition rehabilitation centers were extremely positive about the program set up by MSF in the regions of Zinder and Magaria in the east of the country, certain intellectual and political circles in the capital, Niamey, were very critical of MSF’s intervention. Moreover, the approach adopted by humanitarian organizations during the 2005 food crisis in Niger was heavily criticized. The authorities said that, on the one hand, humanitarian organizations arrived in a region en masse, without any coordination, and, on the other, failed to take into account either local conditions or the strategies already in place, particularly with regard to agricultural development.
In Liberia, however, local authorities had a positive perception of MSF’s work because it was seen as bridging the gap in medical care. Nevertheless, all respondents underlined their concern about the lack of information regarding the transfer of MSF’s medical activities upon its imminent departure from the country. In Kenya, the government administration encourages people to attend MSF’s clinics.
It would seem that a shortage of local facilities and the inaccessibility of medical care are additional arguments in favor of the organization. Populations in remote areas of Cameroon, for example, and the prison authorities in Kyrgyzstan welcomed MSF’s medical assistance, as such treatment was previously non-existent. By contrast, medical aid was viewed almost as a humiliation in Iraq. This brings us to the question of the humanitarian aid system.
In all the contexts visited, the medical actors interviewed and the main partners of MSF projects regard the organization as a reliable and competent partner, an essential provider of medicines and equipment, and an expert in the medical field. For example, in Guatemala, the staff of the Ministry of Health described MSF as a partner that contributes to improving the quality of treatment delivered and lightens their workload.
Medical personnel and health authorities expressed a number of concerns linked to communication about projects and working methods, the duration of MSF’s presence in a given region, training and the transfer of knowledge to local medical personnel, the coordination of activities, and so on. For instance, medical actors in Cameroon complained that the expatriate doctors work in a “closed circle” and prefer to treat their patients without involving or integrating national specialists or training national health personnel. In addition, the medical authorities described MSF’s attitude toward them as sometimes inconsistent (broken promises, unclear schedules) and often critical.
In Kenya, MSF contacts in the Ministry of Health voiced grave concerns about MSF’s use of generic drugs instead of officially registered drugs. Likewise, they complained that MSF financial aid did not go directly to the Ministry as part of a capacity-building strategy. It is important to note that MSF accepts these two criticisms, as they reflect strategic choices. While the Kenyan medical authorities commend MSF’s ability to work in remote areas of the country and involve the community in disease screening initiatives, they question the recruitment of international doctors to manage medical projects. It seems that they would prefer the empowerment of local resources, which they consider to be equally skilled, knowledgeable, and professional as foreign personnel.
Summarizing the opinions expressed by institutional partners, it is important to stress that the medical expertise and competence of MSF’s teams appeared to be highly appreciated in all the contexts analyzed. Nevertheless, the presence of foreign doctors was questioned by some medical authorities concerned with the “balance of power.” Similarly, concerns were expressed about the integration of the program into national structures, strategies for transferring medical activities, the training of local personnel and the transfer of knowledge to reduce dependence on MSF’s services.
It is worth highlighting the striking differences of perception depending on the proximity to and use of the health centers run by MSF. Indeed, it would seem that the further away and less informed the authorities are about the organization’s activities, the more critical or negative their perception. This observation should encourage us to remain attentive to the quality and frequency of contacts established and maintained by the leaders of field projects with the authorities of a country.
Perceptions Among MSF Staff
In practically all contexts, the people questioned stated that the main reason they work for MSF is the need to have a job and the fact that MSF is considered a good employer. Working conditions are not limited to salary or social assistance. Employees mentioned the good atmosphere on projects, the fact that their opinions were taken into consideration, the offer of good training, attractive internal and external career opportunities, and the opportunity to speak foreign languages. Most staff felt well-informed about the projects, but said they did not have the opportunity to participate directly in the development and implementation of strategies.
In Kyrgyzstan, almost all employees mentioned that they joined MSF by chance. In other contexts, such as Iraq or Guatemala, medical personnel stated that they had already heard about MSF and its projects elsewhere in the world before applying. Working conditions were one of the main indicators cited for assessing their satisfaction at work.
In other contexts, although some national employees had already heard of MSF, it was through working on its projects that they came to admire MSF for its humanitarian identity. In Cameroon, some employees had gone even further and joined the MSF-Switzerland association, saying that they were proud to contribute to its development. It is interesting to note that most international workers did not specifically choose MSF from among the variety of humanitarian agencies, either. However, most of the international workers interviewed said that working in the humanitarian sector was something they had been considering for a long time, and that had influenced their professional and academic choices.
National staff in Niger were not very well informed about the organization’s principles and interventions, despite the fact that many of them had been working for MSF since the beginning of the project.
Overall, teams thought that the organization did not communicate enough. They felt that better communication would help both to define the organization’s position in itself and to raise public awareness about health problems. Furthermore, national employees in Kenya saw major limitations in MSF’s willingness and ability to tackle the medical needs of the population.
Turnover of international workers, their presence, and the balance of power were discussed in all the countries visited. In Cameroon, in spite of an excellent overall impression of cooperation and exchange between national and international staff, difficulties linked to the high turnover of MSF field workers were mentioned by the majority of national employees. Moreover, the presence of international workers was often perceived as a lack of trust in national staff and as a “culture of control.”
In Iraq, the general perception was that MSF is an international organization that hires locals, but that senior staff and decision-makers are strictly European. The high turnover of the teams was cited as being unsettling not only from an operational point of view, but also for analysis of the context. Indeed, international teams need time to adapt to the context and national staff find it hard work having to continually repeat explanations about the country to new arrivals in the field.
The role of national staff has almost always been seen as one of “implementation,” where they are responsible for carrying out the decisions taken by the international coordinators, but without having a direct influence on the actual decision-making process. The national staff have always considered their position frustrating and lacking acknowledgment. Various employees—both national and international—stated that responsibilities should be shared to improve the follow-up of project activities and improve HR policies.
In all contexts, the lack of exit strategies and mechanisms for transferring skills and empowering national structures generated debate and concern. In Iraq, it was stated that successive closing and reopening of projects was harmful to MSF’s image. The organization should be flexible and suspend operations rather than closing them altogether.
Doubts were raised about cultural sensitivity and understanding of context in some countries. For example, Iraqi national staff recommended sending experienced MSF field workers who speak one of the local languages to improve acceptance of the organization in the region. In the Occupied Palestinian Territories, national staff pointed out that the authorities’ understanding of the terms “emergency,” “security,” and “without borders” differs from that of MSF, sometimes giving rise to unnecessary tensions between the organization and the authorities.
Internal and external communication practices were severely criticized by both national and international staff. Frustrations with project design, management and exit strategies, and the balance of powers within MSF missions were expressed on numerous occasions. The teams seem to have very limited knowledge of the organization’s history and principles, or awareness of communication strategies.
Perceptions Among Other Institutional Actors
It was important for the ICRC to set itself apart from other organizations and US actors in Iraq. In this respect, only institutional communication and visibility policies secured the ICRC access to vulnerable groups and ensured the security of its personnel. To achieve this, a thorough dialogue with all the stakeholders present proved necessary. Consequently, in the opinion of ICRC respondents, the high turnover of MSF staff makes it difficult to establish long-lasting contacts and diversify its network of partners, which, in turn, makes the organization vulnerable.
Human resources management was mentioned in relation to different aspects of MSF’s image. In Iraq, having a network of medical and non-medical partners was considered the organization’s main strength in operational terms. The issue of staff turnover and a lack of mature, experienced teams in a complex and demanding environment was perceived as one of the biggest challenges for human resources management.
The fact that local NGOs are regarded as being politicized in the Middle East is an important factor to take into account when choosing which ones to collaborate with. In this respect, disseminating information about MSF’s financial independence could be perceived as a major advantage in a complex and politicized humanitarian space in which the UN has questioned the existence of humanitarian principles. The specific attention given to funding sources, especially in the context of the Middle East, was regularly referred to by respondents.
MSF’s adherence to its principles was mentioned as differentiating it from other organizations within the context of operations in Iraq and Afghanistan, where the mixing of military and humanitarian interventions creates security problems. In the theaters of the war on terror, the representatives of the United States have declared in their official discourse that NGOs are the “multiplication factor” of humanitarian strength and the “soft power,” implying that they represented the other face of military intervention. That has generated confusion between military forces and humanitarian actors in the minds of the population and insurgents. In fact, it has also given rise to a dilemma for some UN agencies that are part of both the political system and the humanitarian apparatus.
This need to make the actions of MSF public was often mentioned by such stakeholders as the staff of the Office for the Coordination of Humanitarian Affairs (OCHA): “MSF is on the extreme side of the purity of humanitarian action, while at the other extreme are NGOs working with the MNF-I. A continuum of all NGOs is important, because not everybody stands for MSF’s purity. . . . No one is actually purely following Dunant’s principles.”
Various respondents mentioned the need to participate in humanitarian forums. The ICRC explained that it shared the same analysis as MSF with regard to working in “clusters,” but that it preferred to participate in those meetings in order to remain informed.
Medical aid also seems to have become politicized. According to the French Consul in Erbil (Iraq), MSF should treat patients while also trying to make long-term changes to the health system:
I really regret that the knowledge, the competencies, and the proximity that characterise MSF can’t be used to improve the health system in place or, at least, improve the health system of the hospital close to MSF’s projects or train the medical staff of that hospital. A medical act leaves a political trace. When the NGOs leave, they will have left nothing; they will have only shown that Westerners know how to do things properly while the local government does not, and the health system will not have improved as a result of their presence. MSF is the only NGO that is financially independent, but people aren’t aware of that—neither the Ministry of Health nor the other stakeholders. You should say it loudly because it’s important to let people know that you are not funded by any government. You should also take the time to explain your strategy to your partners, explain that your strategy isn’t linked to fundraising.
MSF’s lack of communication and coordination with other international organizations, NGOs, and local associations was a major topic of discussion with all respondents. It is a serious problem that hinders MSF’s work and has an effect on its image, the security of its personnel, access to aid beneficiaries, and the effectiveness of its projects.
All participants, in several different contexts, stressed the same recurring themes: the importance of perception and public image for security, the local approach to security, the importance of local contacts and networks and the vital need to maintain those networks, the perception of differences, discussions about the applicability of principles, the dissemination of project achievements as a basis for public communication, and the need to adapt HR management.
We have now looked at all the themes that were addressed during the field surveys.
Lack of communication concerning MSF’s objectives and identity was raised frequently by our respondents. In most cases, people know about the organization because of a previous intervention in the region (Iraq, in 1991, for example) or because of interventions that have received high-profile media coverage in other regions of the world (natural disasters such as the Haiti earthquake attract a lot of media attention). However, people who are not employed by MSF seem to have little understanding of ongoing projects and what differentiates MSF and its objectives from other organizations working in the region.
A lack of coordination and collaboration with local and international actors was mentioned as a consequence of an excessively literal interpretation of the notion of independence. Many would like to see greater collaboration with other stakeholders, including national health systems, to make MSF’s missions more sustainable. People often express their concern about the dependency that the organization creates and the medical and economic consequences of its departure. More training is requested, not only for national staff but also for civil servants and certain government employees, in order to guarantee the sustainability of medical action.
Although one of the main working hypotheses was knowledge of MSF’s financial independence as a key aspect of its hallmark, the study showed that the general public are generally unaware of its funding sources. Similarly, at the start of the study, we postulated that the perceived quality of aid projects would be one of the main criteria determining acceptance of the actor. Recognition of the medical quality of the projects implemented by MSF at all the field sites visited was noted by the vast majority of respondents, but some believe that the organization’s medical intervention choices are not always appropriate.
Another initial hypothesis was that being an external (rather than necessarily Western) actor was more important than all the other considerations for acceptance. All the responses disprove this, however. As we have seen, the analysis and interpretation frameworks of local populations do not necessarily include this dimension. The premise that the proximity of the teams to the population contributed to a positive perception was generally disproved. Indeed, to the contrary, security management measures usually created a distance between MSF’s teams and the local populations.
Perceptions among MSF staff were one of the key elements of this research project. As long as there continues to be a lack of communication with national colleagues about MSF’s identity and actions, it is wrong to think that the host society will be familiar with the organization. There is a widespread idea among international employees that national staff members working on MSF projects are intermediaries between the international teams and local populations and are, therefore, the best vector for conveying messages to the population as a whole. This idea does not hold water for several reasons. The first is that, generally, apart from at very specific times of crisis, little information about the organization per se is disseminated to national staff. The second is that the organization’s associative nature is rarely explained or, in any case, rarely understood by the national teams in the way headquarters would like. In the Occupied Palestinian Territories, for example, local associations and organizations created at the start of the 1980s were usually set up as an alternative to the political parties banned by the occupying power. The idea of a nonpolitical association is therefore imported, and sometimes difficult to understand. The third reason is that, within the teams, MSF is, and will remain, first and foremost, an employer in countries where the situation is generally difficult for the population. The high turnover of international staff makes it difficult to establish long-lasting contacts and is believed to hamper MSF’s understanding of contexts and ability to act.
At field sites, we received requests for investment in the training of local health workers and in infrastructures, for a variety of reasons. In Cameroon, for example, at the Akoloninga project, which treats Buruli ulcer, local health personnel employed by the Ministry of Health lack knowledge of this disease and the latest advances in dressings. According to several respondents, the training of health workers by MSF would make it possible to continue treating this disease after the organization has left Cameroon. In Iraq, although there are health facilities in place, the war has seriously disrupted medical training. Moreover, many organizations, including the ICRC, have donated large amounts of equipment and drugs, which means that Ministry of Health staff and private health facilities have a greater need for medical training, particularly in specialist fields, than for medical equipment.
International staff do not always have a good understanding of the political, economic, and cultural contexts in which they work. In any event, the image the organization transmits is that of a western NGO. MSF is sending field workers with increasingly technical profiles into the field, overlooking generalists who might be better able to understand the complex contexts. Respondents suggest that MSF move away from this technical model, instead placing more emphasis on general profiles in each mission, making it possible to develop links with authorities and the community. Moreover, it would be interesting to study the relationship with power and its exercise by coordinators—the type of leadership they choose, for example—and the consequences on image-building among those who are exposed to MSF.
MSF’s quality standards were also questioned. Some informants considered the standards too high to enable them to be taken over by national authorities. Others, particularly within the organization, think that MSF should always strive for excellence in its standards.
It is important to note that a population’s analytical framework significantly influences its perception of an organization such as MSF. As analyzed above, religion was eventually incorporated into this study, although it was not initially included within the scope of the research.
Finally, MSF should definitely get back into the habit of negotiating with the parties involved: politicians, ministries of health, and local people. In the practice of humanitarian action, perhaps because of excessive confidence in the power of humanitarian organizations, there has been a tendency to neglect these negotiation processes. They are, however, indispensable.
Concerning the caregiver/care receiver relationship, a great deal of internal work still needs to be done. This was discussed at length, as we will see below.
In most projects, step-by-step explanations to help patients understand medical treatments are lacking. This issue requires sustained attention in the majority of projects. Nevertheless, the direct impact on patients is what sets MSF apart from other organizations. These studies of perception have enabled teams to become aware of their environment, to be less focused on their own projects, and to understand that MSF is part of a broader system, the workings of which need to be understood. Perceptions that do not correspond to what we would like to hear are not the result of misunderstandings, but reflect reality. The process of changing perceptions, should that prove necessary, is not just a matter of communication, but rather a problem of institutional identity and exercising that identity.