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The Dynamic Generated By the ProjectInternallyOver the project’s three years, it has had real repercussions within the organization. First of all, an important aspect has been to involve the MSF departments in the research in order to ensure subsequent appropriation of its results. Unsurprisingly, the Operations Department has been the most concerned, as it was in direct contact with the research team before and after field visits. The individual country reports, written following each visit, made it possible to quickly modify certain facts, behaviors, or strategies which could have a negative effect on the perception of the organization. Perception is now a dimension that is integrated from the start of each project. For the Medical Department, although the themes of “caregiver/care receiver relationships,” “vertical programs,” and “ethical questions” were present before, they are now the focus of specific research programs. Meanwhile, the HR department has developed a number of procedures, such as the briefing of expatriates (what type of information should be given to people going into the field regarding the context, project, and socioeconomic characteristics of the populations targeted by the project), volunteer profiles (a technical or more general profile, as advocated by some), and training (the recommendations and trends that emerged from the study have now been incorporated into all training in order raise the awareness of people going into the field). MSF’s Communications Department has also reviewed its policies in light of the results of the study. There is now increased motivation to decentralize the apparatus (communications officers are now more systematically recruited at field sites) and the target of communications activities (from communications directed toward the societies where the operational centers are based, i.e., Europe and North America, to communications geared toward the societies where MSF has its operations). Technical assessments of the projects have also included the dimension of perception. For example, the assessment of the activities of the first three months following the earthquake in Haiti, in January 2010, took into account for the first time patients’ perceptions of the medical response provided by MSF. Numerous presentations of the study and its results have been given in all MSF sections as well as to other NGOs, which have then been able to address the issues for themselves. Furthermore, the study has prompted considerable debate within the organization, with several General Assemblies focusing on the subject of perception. ExternallyTwo working days were consequently organized in Geneva on September 30 and October 1, 2010. The purpose was to share the results of the research with other MSF sections. We also asked external speakers to offer an alternative view of our topics, which can tend to be very MSF-specific. The two days were organized along the following lines: a few external guests gave reasonably short presentations, then the participants were split into working groups to discuss the issues raised in the presentations and by the Perception Project itself. The first day was dedicated to political issues. We tried to understand how the gap between perception and reality influences medical humanitarian action. Several research projects, including this one, have shown how crucial it is for humanitarian aid actors to understand how they are perceived by local, regional, and international stakeholders, and how that perception can affect their capacity to implement effective operations. There are clearly discrepancies between the way organizations are actually perceived and the way they think they are perceived. The second part of the session was more focused on developments in the political context of medical humanitarian action. The participants explored the possible benefits of those developments for actors such as MSF, as well as their repercussions on the aid system more generally. External participants presented some recommendations. According to them, the briefing of MSF field workers going into the field should be improved and deepened, so that they understand all the implications of their work in a specific context. In addition, the teams should take the time to explain the project that is going to be set up to local people, how it will function, admission criteria, and so on, in order to avoid any misunderstandings with communities or patients. According to Li Anshan, the central goal in humanitarian aid is to prioritize the transfer of knowledge to the local population. Antonio Donini highlighted four points that can illustrate the different perspectives of people in the field: the universality of humanitarian values, the effect of policies resulting from the “global war on terror” on the perception of international NGOs, the manipulation of humanitarian work by the political world, and problems related to the security measures taken by international NGOs. NGOs should prepare to deal with new non-Western international actors in the field: this development also reflects a stronger challenge to the dominant Western discourse. It is envisaged that in 10 or 20 years’ time, the Western point of view will carry less weight than Brazilian, Chinese, and Indian perspectives, for example. The institutionalization of humanitarian action has contributed to the shift from a “powerful discourse” to a “discourse of power.” Perceptions are important because they give meaning, but they can also have very negative consequences for humanitarian actors. In order to change this and move forward, it is necessary to work in close collaboration and establish new relationships with all stakeholders. The points discussed following the presentations can be divided into four different categories: points on which the participants reached a consensus, points on which opinions diverged, unresolved questions, and, lastly, recommendations emerging from the discussions. ConsensusMSF’s added value is its medical identity. That enables it to maintain privileged links with medical circles and project an image that is clearly understandable for the majority of actors. The recognized quality of the care it provides and its appropriateness for the needs of the populations is, without doubt, the best way of becoming accepted. Several participants highlighted the fact that the organization prompts changes in local health care systems and challenges certain local medical protocols which sometimes have not evolved for decades. It therefore has a considerable role to play in the field of medical innovation thanks to its ability to undertake costly long-term programs (treatment of tuberculosis, putting patients with HIV/AIDS on antiretrovirals [ARVs], etc.). As MSF does not have a delegation of authority or mandate from the states signatory to the Geneva Conventions (as the ICRC does), the interactions between MSF and states that are reasserting their sovereignty require much more negotiation than in the past. Although nowadays NGOs inevitably have a discourse of power, they are nonetheless confronted with state actors who challenge that power. MSF will always be viewed as an organization external to the context and will always have to explain its intervention criteria and programs to authorities, and especially to target populations. A real investment should be made in dialogue with the main partners and beneficiaries. MSF cannot and must not totally remove the gap between reality and perception. Sometimes, keeping a certain distance can be a real strength. Thanks to its independence, the organization is able to tackle medical problems without any political or economic interests coming into play. MSF should nevertheless be aware of the way it is perceived and change that perception through concrete actions, by adapting its organizational identity. According to participants, MSF should work on reducing its isolation (by establishing contacts with the populations for and with whom it works, gaining a better grasp of the circumstances in the field, etc.). This can be achieved at two levels: at the international level, by becoming a more influential actor, and at the local level, by trying to have an influence on the regions around its projects. There is a consensus that, as an organization, MSF is in fact a very influential political actor and must, therefore, be more involved. A good image among the local population is not an aim in itself, but strongly influences a project’s success. Debated PointsSeveral participants were keen to provide additional details about some of the points raised in the presentations. First, they stressed the fact that criticism of MSF (arrogance, vehicles, isolation, etc.) does not reflect the work of volunteers in the field, who are sometimes very close to the local populations. MSF is not systematically isolated. The question of medical standards also elicited divergent points of view. Several people underlined the fact that standards within the projects were too high to enable a smooth handover to the local authorities. Others, meanwhile, highlighted the need to provide the best possible quality of care, even if that makes an exit strategy more difficult.
MSF should expand its networks and make contact with all the stakeholders present in the contexts in which it acts, while avoiding any manipulation for political ends. According to The reassertion of sovereignty by some state actors and the reshaping of international relations (the growing power of actors such as Brazil, Russia, India, and China) prompted heated discussion. Indeed, some participants thought that MSF should welcome the rise in power of certain states that are now better able to take care of the medical needs of their populations, while others pointed out that a recovery of control could be detrimental to some populations and that the organization should ensure that the provision of health care was adequate. In this context, the notion of independence can be a source of confusion and misunderstanding. Indeed, the boundaries between political independence, financial independence, and technical independence (i.e., operational independence from other groups in the field) are sometimes unclear. The question of the impartiality of MSF’s work was addressed. Some called for clarification of the definition of the criteria for intervention and asked why some populations seem to deserve more help than others: Why intervene in Iraq rather than Laos, for example? Impartiality is a clearer concept than neutrality and should be MSF’s guiding principle. Neutrality was described as being less and less pertinent. The political choices behind the decision to intervene in a given country were also debated, on the basis of two considerations: MSF’s political will to be present in complex situations, and the medical needs of the populations, which are not always sufficiently pressing. Finally, for some participants, constraints in terms of the management of human resources are considered detrimental to MSF’s investment in certain more complex contexts. Unresolved QuestionsSeveral questions remained unanswered at the end of the discussions, but deserve to be addressed. The perception gap—that is, the difference between the way MSF thinks it is perceived and the way it really is perceived—has still not been clearly defined. What gap are we talking about in terms of perception? What is the definition of perception or a perception gap? Can we talk about its security implications, knowing that nowadays perception is directly linked to a specific time—the evaluation, exploration, and setting-up of a project? Will the gap between reality and perception decrease if MSF is perceived as less Western or, on the contrary, adopts a clear Western position? What ethical considerations come into play in the constitution of this perception gap? MSF should be careful not to establish an overly paternalist relationship with patients and populations, considering that the organization already decides, when setting up a project, what it considers best for those populations. Participants all felt that MSF should take more time to explain its position, highlighting the medical aspect of its involvement, which is the only objective element in the construction of its image. RecommendationsA set of recommendations was developed based on these discussions. First, MSF must establish cooperation with actors in the political sphere, while taking care to avoid being exploited. Next, it should be more consistent in its public positioning, communication, actions, and advocacy work. It must adopt a more “readable” position. Concerning communication, several issues were underlined. First, participants said that the organization should be much more precise in its communication. It still presents itself as an emergency relief organization, while a large part of its programs are not perceived as such, either internally or externally. Second, because of the increased bureaucracy within MSF, messages tend to lose their substance and become less political. Third, the target audience for MSF’s communication is mostly Western, when it should be focusing on the countries where it has operations. The second day was dedicated to the medical aspect of MSF. The effect of medical humanitarian aid on fragile health systems is often questioned (recovery of costs, handover, co-infections, neglected diseases, etc.). Does medical humanitarian action add value to public health systems? To what extent are medical structures taken into account in conflicts? The general consensus is that the medical field has become politicized as well. The day was structured around three main themes. The first was the perception of humanitarian medical action by its “beneficiaries.” Samia Hurst, from the University of Geneva, demonstrated the shift from a model of all-powerful medicine, which has at its core an attitude of charity toward the poor, to a model of medicine more attentive to patients’ expectations and the emergence of the right to receive medical care. In this context, the main challenge for MSF as a medical organization is to define its priorities. In practical terms, who benefits from what? The second was the perception of humanitarian medicine by other actors. Paul Bouvier, from the ICRC, highlighted that the issue of perception is skillfully exploited by power holders to win the trust and secure the cooperation of local populations. In his opinion, it is precisely because humanitarian action is viewed in a very positive light throughout the world that military forces, bankers, and big businesses want to establish close collaborations with NGOs, or even set up their own charitable organizations. The last topic addressed, in a presentation by Jean-Hervé Bradol, former president of MSF-France (2000–2008), was the impediments and synergies between humanitarian medicine and public health systems: Jean-Hervé Bradol, former president of MSF-France, research director, CRASHI would like to talk about the relationship between MSF and public health policies. Since MSF’s creation, we’ve been involved with public health systems in various capacities, even, in the most extreme cases, by delegation (from local or national authorities, or by choice). For instance, in refugee camp settings, UNHCR is often over¬stretched or lacks qualified staff to coordinate the medical operations, and we are then asked to step in and perform the role of “Ministry of Health” of the refugee camps. In more open contexts, outside the camps, some of us have assumed the role of provincial health director, for example, for the public administrations in countries like Guinea, Chad, the Democratic Republic of Congo, and Burundi. MSF can play a wide variety of roles: it can substitute the teams of the Ministry of Health, or simply act as a private-sector agent, in competition with the public health system. So, in 40 years, we’ve performed all sorts of roles. We’ve supported most of the major drives that have made it possible to establish what is known today as “global health.” The first operation of this sort was the 1974 expanded program on immunization (EPI), which MSF supported and helped implement in a modest capacity at the start of the 1980s and throughout that decade. It has also supported primary health care: at the interna¬tional conference in Alma-Ata in 1978, MSF defended the policy of developing primary health care, while pointing out that the ultimate objective was utopian and the means of achieving it were inadequate. That’s why, in 1987, the Bamako Conference constituted a turning point, establishing new guidelines for managing the human and financial resources of structures in charge of primary health care. I know that for some of you it won’t quite fit with the MSF “legend,” but I remember that one of the first positions that was offered to me by the French section, in 1989, was as a doctor for the public administration in Kankan (Guinea). This type of work may seem to contradict the perception of a French section that steers clear of development actions, but historically, that’s not true. MSF has also done a great deal, not only to promote the subsidization of user costs, but also to harmonize the care provided. In the 1980s, it became important to establish national protocols, and one of the points at the center of the debate at the time was the WHO list of essential medicines. That was a major advance in terms of public health, and MSF firmly supported the initiative. Those years also witnessed an improvement in the international medical response to crises; MSF was obviously one of the contributors to that international response. More generally, during that period, at its field sites, MSF did a lot to spread the word about “biomedicine” and evidence-based medicine, through Epicentre and MSF’s publications. Looking through these medical publications, it is impressive to note that, in some medical fields, MSF provides a large part of the scientific data. The question of how well MSF understands the different socio¬cultural contexts in which it works is often asked. Today, the “typical profile” of a caregiver in an MSF project is an African woman of around 30 years old; she is more likely to be a nurse than a doctor; she speaks the local language, and is familiar with the prevailing cultural context in her region. Consequently, the following question is asked: Are local staff given an appropriate position within the organization? From the point of view of the patients, if they need a consultation, they will be seen by people who speak their language, even if it’s not the language most commonly used in their country. I’m not implying that there are no intercultural difficulties, but having an organization of 25,000 employees in 70 countries, 90 percent of which are nationals of the country in question, clearly illustrates the reality of cultural interactions within MSF. Unfortunately, there is still inequality in access to positions of responsibility between people who join the organi¬zation in their own country and those posted abroad. Obviously, we are more in favor of public health institutions than private health institutions. I would like to add, briefly, that this ideo¬logical position is actually largely unfounded, because throughout the history of public health systems, there has been major contribution from the private sector, even in the case of one of the key countries when it comes to public health education, namely the United States. For example, the Rockefeller family and the Rockefeller Foundation contributed considerably to the development of the public health system in the United States. The Gates Foundation also plays a clear role today. In the debate about development, there were two main trends: one advocated a style of development based on public services and taxation to cover the expenses of those public services, while the other trend was more based on individual rights and a market economy. Throughout most of MSF, the culture that is still dominant in the minds of the majority of volunteers is that of public services and public institutions paid for by taxes. One of the other comments made to us concerns the sustain-ability of our actions to support the development of public health care institutions. So we made a choice—which needs to be re-examined, because it is rather a political choice, that was made in a very specific historical context—but overall, we were in favour of the creation of public health institutions. We’ve tried to contribute to them, but it hasn’t always been successful. Field operations like those launched after the Bamako Conference, at the end of the 1980s, were generally classed as failures. That’s not to say that we didn’t learn anything from those experiences, but most of us have stopped making it our operational focus. The same applies to management, because although we were in favor of developing public health institutions, it was often pointed out to us that we were not sufficiently legitimate or qualified to contribute to their development, since what we intro¬duced in those public health institutions wasn’t sustainable. An entire discussion could be devoted to this point alone, as when MSF contributes to the modification of national protocols for malaria, tuberculosis, or the AIDS virus, isn’t that a sustainable action? When MSF participates in the importation of a new generation of treat¬ments into a country, that’s an extremely sustainable public health action. The example of Haiti is interesting. It’s understandable to be pessimistic about the building of public health institutions in Haiti today. In the current social, political and economic situation, it’s difficult to identify the necessary conditions to establish quality public health infrastructures. In Haiti, the situation is a bit para¬lyzed because the legitimate actors, such as the state, perhaps lack the necessary will, and those who have the means are not legitimate (I’m talking about the UN, the United States, etc.). They lack legitimacy, at least in the eyes of the population of Port au Prince, for one obvious reason: they’re foreigners. That comes across very clearly when you talk to people. In this type of context, medical centers dependent on religious structures or groups are very common: they are private and religious, but are recognized by the Ministry of Health as contributing to public health. And if you want to partic¬ipate in the meetings that coordinate that kind of activity, for me, it’s a tactical question: Are those meetings effective? What is their dynamic? That’s why I started by mentioning that MSF has histori¬cally adopted a wide variety of stances on these matters, ranging from deep involvement to adopting an arms-length approach to public institutions. There’s also a great deal of discussion about the process of selecting MSF’s target populations. The choice is obvious when responding to an acute disaster, but less obvious for chronic disasters, and in situations where access to care is very limited, what MSF’s role should be remains to be determined. Another controversial point is that MSF has been one of the few medical organizations participating in the public debate on trans¬national health issues in various circumstances. Today, and over the past five years, one cannot help but notice that MSF is participating less and less in the debate about the international response to wars, or to conflict situations more generally, but is increasingly active in the political debate about global health issues. MSF even has what could be described as an “advocacy unit” with the Campaign for Access to Essential Medicines, which is entirely dedicated to this activity. It’s not that common to see a medical organization getting so involved in the public political debate about health issues. MSF has also participated in training activities, contrary to what has often been said. That training has been technically successful and we’ve learned a lot from it. Technically speaking, it’s been a very interesting and fruitful experience, but from a social perspective it’s been very difficult, because when you’re not in control or you’re not fully integrated into the system, staff training is a waste of time, because they never end up working where they would be most useful from a public health point of view. In the debate on sustainability, public institutions are always portrayed as being sustainable. In our environment, if we base our assessment on a set of objective criteria, the structures of the Ministry of Health have been extremely unstable. You know, we arrived shortly after decolonization. In the 1980s, in Africa, most of those structures collapsed, for a number of reasons, notably the structural adjustment policies implemented by the World Bank and the IMF. Consequently, the setting was completely unstable, yet ideologically, when we talk about the Ministry of Health, we think “stable,” and when we talk about private structures, including MSF, we think “unstable.” However, in many situations, we are actually more stable in that environment, in terms of service delivery, than the public institutions. In my view, it is a political bias. Two main issues were addressed in the discussions on the second day. The first concerns the very notion of “beneficiary.” Is it the group that benefits from the medical act itself, or the broader group that benefits from the intervention? Some people explained that the use of this word is not neutral, as it creates a certain order of things. By delivering a benefit, the organization is contributing something positive. The terms “victim,” “patient,” and “beneficiary” underline the fact that the person is in a state of suffering. The term “user” places the emphasis on the fact that the person in question is using a service. That draws on the principle of mutuality and reciprocity of giving. Humanitarian aid implies an imbalance and an asymmetrical relationship. Although “beneficiary” may not be the most appropriate word, the term “client” also sounds odd. “Patient” is an outdated way of viewing medicine and the latest definition of this term does not really reflect a sense of autonomy. It doesn’t come naturally, from a medical point of view, to refer to a patient as a “beneficiary,” since the term has economic connotations. Use of the term “beneficiary” establishes a paternalistic attitude toward the patient. That being the case, is it MSF’s role to define who its beneficiaries are? Shouldn’t it be left to the people themselves to answer that question? MSF should merely define a target group. To conclude, the term “beneficiaries” has been highly criticized, first because it implies a certain passivity, second because MSF is not actually expected to provide a “benefit” but rather to improve access to health care, and, finally, because patients do not seem to regard themselves as “beneficiaries.” The second issue concerns the caregiver/care receiver relationship. MSF must ensure that its teams connect with patients. We should “take time to have a cup of tea.”[1] Similarly, it is important to give consideration to friends and relatives, in order to make more of a connection with the communities and to care for patients better. Care staff must clearly explain the stages of the treatment and the consequences of the disease. The idea of having a users’ charter was mentioned several times. MSF should take time really to understand how medical services are organized around the person being cared for. We must engage more with patients, as caregiver/care receiver dialogue and the feedback process are essential parts of the medical procedure that warrant greater attention. We must take our responsibility toward patients more seriously (there’s a link between dialogue and the quality of medical care), as it is essential for generating a positive perception of the organization. Human dignity was identified by everyone as the element that should be at the heart of MSF’s medical apparatus. To conclude, it was pointed out that MSF’s weight today gives it certain responsibilities. The process of placing more emphasis on some diseases over others is not insignificant. These responsibilities are towards patients, donors, and the target populations, as well as towards the governments of the countries in which MSF works. Although medical structures are increasingly implicated in political conflicts, the fact remains that the relationship between caregivers and care receivers must be depoliticized. The two days of discussions ended with a speech from the President of MSF International, who reflected on the organization’s position in the new landscape of global health actors: Unni Karunakara, president of MSF International since 2010Setting up health systems requires the kind of commitment that we’re probably not in a position to provide at the moment. Health systems need planning and long-term commitment, an ambition that must come from the national government, with the participation of civil society and other nongovernmental actors. We’ve already talked about some of the constraints that need to be addressed, such as human resources. We should also discuss mana¬gerial and large-scale control capabilities, as well as the setting up of national supply and distribution systems. Health systems require solid management of epidemiological capabilities and information, in order to be able to predict and deal with epidemics. It’s also necessary to have stable, long-term funding, bearing in mind that in most of the countries in which we work, only a small percentage of the funding comes from the country itself. Most of the time, the budgets allocated to health are determined by the Ministry of Finance, which has little understanding of the health needs of the population. Consequently, it is mainly international actors such as the WHO or the Gates Foundation that steer or influence health sector spending in those countries. A major transformation has taken place in the world of health over the past 10 years. In 1999, when we received the Nobel Peace Prize and later decided to create the Campaign for Access to Essential Medicines, many influential agencies and organizations, such as the Global Fund, the Gates Foundation, the Clinton Foundation, PEPFAR (the US President’s Emergency Plan for AIDS Relief) and the President’s Malaria Initiative, to name but a few, didn’t exist. Since then, billions of dollars have been spent to provide popula¬tions with treatment against certain diseases and, lately, to address problems linked to health systems. Numerous international political entities have also expressed an interest in getting involved in ques¬tions of global health, although many of those promises do not translate into a significant injection of funding. Although there’s still a shortage of funding to tackle the glaring health problems, more attention is being focused on global health today than ever before. As a humanitarian medical organization, we must clearly state that our mission is to save people in distress and not health systems in peril. Of course, it goes without saying that we must collaborate with the health system of the country in which we’re working, so that we can help its population and provide appropriate care. However, our objective isn’t to take on responsibility for the development of those health systems. Current notions of sustainability depend greatly on capacity- and system-building activities, and securing a constant, reliable flow of funding. In many of our programs, we often make important contri¬butions to the national health systems. We manage to make an impact in the short term by offering training or undertaking collaborative activities. Although we set up these activities and sometimes even work in a country for a prolonged period, that doesn’t necessarily mean that our projects will be sustainable. As our organization grows, we must reflect on what our size and capabilities bring to the contexts in which we operate. Even though our programs have a positive medical impact, our actions could have negative consequences on the health system and the local human resources available for other programs. It’s not our job to define a country’s road map or development program. Of course we can offer our help, but at the end of the day, it’s up to the government to decide which route to take and up to the country’s citizens to make sure the government honors its commitments. I’d like to suggest that we look at the notion of sustainability from another angle. Over the years, we’ve used our operations, our research capacity, and our political influence to introduce health care models that have become the norm in various contexts and several countries. That’s the case in the fields of HIV, malaria, nutrition and neglected diseases such as kala azar, sleeping sickness, and Chagas disease. Whether these initiatives involve introducing a new tool, setting up a new operational or medical approach, designing adapted models of care that can be extended not only by us, but also by governments, they all constitute sustainable actions. Above, I mentioned a list of organizations created within the past 10 years. Those agencies are very powerful, and they have a lot of influence and resources that can serve to establish a global consensus and start global action. However, we remain an organization with a strong presence on the ground, which treats patients and shares its expertise. No other organization’s programs match the scope, caliber and depth of ours. But how can we get those agencies to provide better conditions and better treatments for our patients? We still have a very important role to play in this new world of health, but we need to think about the best way of using our operational experience and our political influence.
At the end of the day, perception depends on the relevance of our operations and our interactions with the host communities. Good communication is vital. We have a gift for communicating with our donors about our activities, but we’re less gifted at informing the communities with which we work about our principles and opera¬tions. As the implementation of our humanitarian mission becomes more complex, we must endeavor to explain our challenges, opera¬tional dilemmas, and choices about programs to the public more clearly. This very notion of accountability can only materialize if we treat our donors and host communities as adults and as our equals. Footnotes
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