Tackling institutional discrimination and racism within Doctors Withour Borders

Following a number of allegations of abuse among aid organisations in the Democratic Republic of Congo during the 2018-2020 Ebola outbreak, the Core ExCom prioritised work to address issues around abuse and misbehaviour.

In tackling abuse and inappropriate behaviour, there is clearly a gap between what we should be doing and what we are doing for our own staff and for our patients and their communities. Complaints from Doctors Without Borders staff and association members, as well as public reports, have indicated that there is insufficient trust in both reporting mechanisms and the management of complaints within Doctors Without Borders.

Our internal reviews have also shown that Doctors Without Borders struggles to respond rapidly enough to cases of abuse and inappropriate behaviour in the countries and emergency contexts in which we work. In 2021, we received 490 reports of abuse in our field programmes, including 32 complaints of discrimination (2022 numbers will be published during quarter 3 in 2023). A full breakdown of the number and type of complaints we receive each year from staff and patients can be found here.

Part of the answer to this lack of trust is the need to increase the ownership of these reporting mechanisms and the management of complaints at all levels of the organisation.

A number of initiatives had been put in place during 2021 to address these needs, and progress continued and were complemented by further initiatives developed during 2022.

A mechanism for patient complaints was put in place during the year, and raising awareness of this mechanism among patients is being scaled up.

Also among these initiatives, we have engaged consultants who are working to propose a mechanism, including a governance structure, that would handle the reactive management of cases of abuse and inappropriate behaviour in our programmes when multiple Doctors Without Borders entities are involved. This is in addition to the mechanisms already in place to respond when only one Doctors Without Borders entity is present. The consultants are also working to propose a way of proactively identifying and assessing cases of abuse and misbehaviour. This will include a concrete proposal for the creation, and sustainable management, of a pool of investigators to increase our capacity to examine cases.

The same consultants are additionally working to set up a review and appeal framework related to the management of abuse cases, identifying and proposing a set of criteria and principles on when and how the parties in a case can request a review of the case. This is to provide accountability to the individual parties involved in an investigation, and to maintain and enhance the trust of Doctors Without Borders staff in the overall case management system.  

While the Doctors Without Borders Intersectional Platform on Behaviour (IPOB) has carried out crucial work, a long list of priorities remain which could only have been addressed by increasing human and financial resources within Behavioural Units, at field level and at IPOB level. In October, the Full ExCom agreed a Safeguarding Coordinator would be hired. This role will coordinate the IPOB and its work going forward, including the management of critical cases of abuse, and will gather analysis from our HQ offices and country programmes.

We have also provided dedicated trained staff and financial resources to tackling abuse and racism, and are encouraging our diversity, equity, and inclusion (DEI) and behaviour units to learn from each other’s expertise.

In addition, some pilot initiatives were made to ensure that Doctors Without Borders integrates context-appropriate preventive measures and complaint mechanisms in all contexts where we operate.

“We have listened to feedback from our staff on wanting to be remunerated fairly for their work, and we are striving towards more equity and better transparency on how people are rewarded. The Rewards Review Project is designed to address these issues – while it is a complicated process, we can’t afford not to succeed, for the benefit of all our staff.”

- Dr Christos Christou, Doctors Without Borders International President 

We are aware that Doctors Without Borders’s reward policies and processes do not align with our ambition for a diverse global workforce; are insufficient to fully support our evolving operational and organisational needs; lead to inconsistencies; hamper mobility; and are perceived as inequitable by many of our staff. Specifically: There is a lack of clarity about the principles guiding our rewards and how they are applied or prioritised.  

• Historic staff groupings (i.e. ‘international staff’, ‘national staff’ and ‘headquarters staff’) are outdated.
• Doctors Without Borders offices use different salary scales to determine pay and benefits, which leads to inconsistencies and hinders joint operational initiatives and staff mobility. In some contexts, salaries at the lower end of the scale are not sufficient to guarantee a decent standard of living.
• The current remuneration system for internationally mobile staff is seen by some staff as inequitable and discriminatory because it uses domicile as a basis for determining pay.

To address these inequities, we have set up the ‘Rewards Review Project’ and are in the process of  launching the ‘Doctors Without Borders International Contracting Office’.

The complex requirement for our rewards, the size and diversity of our workforce, and our organisational structure means that the Rewards Review deliverables require time and investment. In line with the original planning, good progress has been made on the objectives in 2022. Key achievements against objectives in 2022 include:

• Development of a proposed new model for groups of staff, which outlines the definition of International Staff and Locally Hired staff categories.
• In October 2022, the full ExCom gave their support for the direction of the project and requested a risk analysis, including stress testing and financial modelling, the design of which has been outlined.
• Completed analysis of existing Doctors Without Borders Minimum Living Wage (which is used to inform pay decisions for locally hired staff) methodology and its shortcomings.
• Work to increase capacity for benchmarking reviews and allow more regular salary updates.
• Agreement of revised Economic Turmoil Policy for salary adjustments in response to extreme inflation.
• Implementation of 4.6% pay increase for all international staff.
• Continued development work and implementation planning on the Global Grading Framework, which aims to score positions on a functional grid across the whole movement, regardless of location.
• Engagement of around 4,000 staff through focus groups and staff meetings for staff input as part of the Rewards review process.

The last years have seen events in which our staff have been endangered; they have been abducted, arrested, attacked, even killed. Improving our understanding on our exposure to risk for certain staff profiles and operations – to prevent these events from happening as much as possible – is an imperative.

In this context, we aim to develop consistent guidelines about which context conditions justify selecting staff according to their non-professional profiles – a practice known as ‘profiling’ – which consists of selecting people according to criteria such as ethnicity, nationality, gender, and religion. Profiling, though, should be used solely for security management, with the aim of mitigating risks for Doctors Without Borders staff and activities. 

The RIOD have opened discussions between the operational directorates (ODs) on current profiling practices across operations, and by the end of 2022, the following initiatives were started:

• Five of the six ODs had put a mechanism in place to ensure profiling decisions are based on analysis, and that each decision made is transparent, enabling an informed choice to be offered to all individuals who leave for assignments.
• A common repository of profiling related documents was created. 
• A deep analysis was conducted on how to better integrate and better understand the “HR restrictions and profiling” for locally-recruited staff in some specific contexts.
• The Core ExCom is updated every six months to routinely include analysis by the RIOD on profiling.
• Identifying a scope of profiling across contexts and ODs, with a focus on comparing HR restrictions on nationalities/passports and physical appearances that are used by all ODs.

That said, individual ODs have made progress on the duty of care, with individual mechanisms put in place – the outline of which is not in the scope of this review. However, collectively, we are working towards guidance for coherent approaches on informed consent for all staff, in line with existing duty of care best practices, including in recruitment, briefing and debriefing.

Doctors Without Borders’s existing staffing model has led to unequal access to recruitment and career development opportunities. This has caused a lack of diversity in team composition; created gender disparities in some staff groups; restricted access to coordination positions for locally hired staff; and resulted in over-representation of staff of European and Western origin in senior headquarters leadership roles.

Our decentralised organisational structure, with multiple legal employers and different HR policies and practices, represents a key challenge when it comes to recruiting and developing our staff. There is no single organisational workforce strategy, and our principles are applied differently across our various operational directorates and other Doctors Without Borders entities. With several of our operational directorates reporting a shortage of experienced international staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff.  

To address these and other inequities, the following objectives were achieved in 2022:

• The development of a new contracting office for international staff with no HR contracting office in their country is well underway, with the full ExCom having approved the governance and operating model. A Human Resources Information System (HRIS) has also been selected.
• A manager and key team members for the International Contracting Office have been recruited and brought on board. 
• A recruitment page on msf.org was launched, so that job vacancies across many Doctors Without Borders offices are accessible to anyone interested in working for Doctors Without Borders; 804 vacancies were published since the site’s launch in April until the end of 2022.
• A new site (rewards.msf.org) with information on ‘Doctors Without Borders as an employer’ and reward policies was launched, accessible to all Doctors Without Borders staff (including those who have no Doctors Without Borders email address and therefore no access to the organisation’s intranet).
• A human resources portal was launched, and all HR policies and guidelines were made accessible to staff with access to an Doctors Without Borders computer; for staff without an Doctors Without Borders log in, we have made policies available on the rewards page on msf.org.

• The 2021 Doctors Without Borders Staff Data and Trends Report, published in July 2022, included new and improved analysis and more detailed reporting on workforce make-up, to help us improve our understanding of our workforce and how it’s changing.
• The platform of Directors of human resources, IDRH, led an analysis of recruitment trends and projections to identify how to optimize recruitment resources and improve gender balance.
  • Initial discussions have been had with recruitment and staff pool managers to scope this.

“We are aware that capturing and telling the stories of human suffering in a powerful way with utter respect for dignity and autonomy, is not just a technical and artistic challenge and it takes more than the review of ethics, updated guidelines, or stricter policies. It takes a shift in our own mindset.”

- Dr Christos Christou, Doctors Without Borders International President 

With Doctors Without Borders communication and fundraising materials the public face of the organisation, calls to ensure that these materials show the dignity and agency of patients and our staff, and to eliminate perceptions of white saviourism, neo-colonialism and racism, have become urgent from both within and outside of Doctors Without Borders.

In early 2022, a DEI guide was produced by the dedicated taskforce that was set up in April 2021. This guide advises Doctors Without Borders teams on the creation of more respectful, ethical and inclusive public communications productions that accurately represent our staff, patients and the communities with which we work.

While there is still some work to do, there has been significant progress made towards achieving the objectives set for Communications and Fundraising in tackling DEI issues in 2022. They include:

• In February, the Peer Feedback Group was officially created to provide feedback on the sensitivity of packages, with an initial group of 18 volunteers from across the movement attending an introductory session on reviewing, and then identifying and tagging images with potentially sensitive content.
• The Media database review, which started in 2021, had had more than 136,000 images on the photo database reviewed at least once by end of the year by an expanded volunteer feedback group in Doctors Without Borders. More than 9,500 had been tagged as sensitive; these now have a warning in the caption awaiting a final decision on their status. More than 2,700 images have been hidden and are now no longer visible, or able to be used, by standard database users within or outside Doctors Without Borders.
• The DEI Guide was endorsed in March by Doctors Without Borders's decision-making platforms for communications and fundraising, the DirCom5 and the DirFund, for further dissemination and to inform specific guidelines across the movement
  • The DEI guide was circulated to Directors and Heads of Fundraising and Communications as a soft launch, before an official and comprehensive roll out starting in April. This action was taken to allow sections to translate the guide, giving access to all staff and permitting initial of conversation within teams. 
  • In June, all Heads of Fundraising present at the International Fundraising Meeting had a working session with the DEI guide.

• In June 2022, the position of DEI Guideline Roll-out Coordinator position was opened. The recruitment of a part-time staff member to take on the roll out of the DEI guidance took more time than anticipated, but the right person was identified and was able to start at the end of 2022. The person is a fundraising professional working in an Doctors Without Borders office and is also a trained DEI facilitator. This specific assignment is a part-time detachment from their usual duties.
• Considering the delay in finding the right person for the position of DEI Guideline Roll-out Coordinator, there was also a delay in developing and implementing a plan for a proactive roll-out towards different communications and fundraising teams across the movement. However, by December a scoping exercise had been started to understand the level and the kind of support that would be needed by different teams.

• Starting with a version in Spanish released in mid-2021, “Guidelines to equitable, respectful and inclusive language in Doctors Without Borders communications” were published in other languages throughout 2022, including in English, French and Arabic. These guidelines, which complement the DEI guide, help Doctors Without Borders content producers, editors and disseminators use the right terms to describe people, crises and contexts.
• The DEI knowledge hub for Doctors Without Borders Communications and Fundraising Professionals, also known as Ubuntu, was launched in September. The aim of this online internal SharePoint hub is to inform and inspire communications and fundraising teams on DEI matters and link to existing internal and external resources on the topic.

The review of Doctors Without Borders’s images on the media database converges with another component that had not been foreseen before. Following internal and external challenges, we were alerted to the fact that there are many sensitive images taken in Doctors Without Borders structures which remain available for distribution by individual photographers or through photo agencies. Some of these images were commissioned by Doctors Without Borders; others were taken in the context of news media visits. Some of these images are problematic, including for perpetuating racist stereotypes, featuring a neo-colonial gaze, lacking respect for the dignity of patients, or failing to ensure child protection.

In addressing this issue, we took the following steps in 2022:

• In June, the Full DirCom (the Directors and Heads of Communications for all Doctors Without Borders sections) issued a statement pledging to accelerate action on multiple fronts to better manage the collection, use, dissemination, and storage of photographs and video taken at our medical projects.
• A person was recruited and started work in November 2022, working as a dedicated resource with photo and news agencies to assess ways to stop or restrict the distribution of certain sensitive images involving Doctors Without Borders through these agencies.
• We are reviewing our standard AV contracts with the aim to strengthen our control over the distribution of images taken within Doctors Without Borders structures.  

Against a backdrop of growing attention to discrimination, racism and accountability, we are developing processes to begin the integration of DEI into our medical policies and activities. At the same time, we aim to reform medical data and activities to ensure that not only can we provide a quality service, but we can also hold ourselves to account for our choices and actions.

Key amongst these activities was the proposal and starting development of a Patient Charter. The MSF Patient Charter is based on the provision of effective, safe, and equitable healthcare in conditions of scarcity and crisis. In October, the International Board’s Medical Steering Committee proposed a set of principles for a Patient Charter which was endorsed by the DirMed. These principles include: Dignity and Respect; Safe healthcare and Protection; Access; Information; Participation and Consent; Privacy and Confidentiality; Feedback and Complaints Procedures. This set of principles will serve as a guide for each operational directorate to use and adapt according to the cultural and context specificities of their project settings.

In addition, throughout 2022, medical platforms and teams across the movement achieved the following objectives:

• In August 2022, a consultant started work on the revision of Doctors Without Borders’s MedOps-led Mutual Accountability process. The revision is meant to improve the tools and methodologies by which Doctors Without Borders measures the quality and relevance of our activities.
• A consultant is also working on mapping the Quality Alliance Working Group’s Annual Plan of action. This includes the development of tools to use evidence-based quality improvement methods (quality glossary, training and workshop package, etc.), and a health incident management system to enable staff engagement in quality-of-care work. Outputs on indicators and monitoring systems used will be crosschecked with the work being done on health data strategy. 
• The DirMed had approved a Data Strategy Concept Note that includes optimization and maximisation of the use of data, a coherent approach across ODs aiming at efficiency, and secure management of data.
• The DirMed-led Improving Collaborative Leadership process – which reaffirms the medical leadership and the collaborative approach for medical support to Doctors Without Borders projects – agreed upon key action points during workshops in 2022.
• The first draft of the working log frame was presented to the Core ExCom and the MedOps for feedback and inputs in June and July, before it was revised and finalised by the MedOps in October.
• The revision of medical and operational indicators for the collective typology is in progress, with medical indicators for HIV, nutrition and in-patient care having been finalised. Review of non-medical indicators is ongoing.
• In October, the research platform, with the Ethical Review Board, reflected on questions of DEI in clinical trials and medical research, looking at ethical perspectives. 

In recent years, we have begun to question how decision-making power should be distributed across the Doctors Without Borders movement and shared with our projects for the benefit of our future social mission. As part of this, we have set up the ‘MSF Structures Project’, which aims to clarify ways in which new voices can become central to our collective decision-making process, while maintaining a solid and accountable governance mechanism. We plan to remove barriers, such as the requirement for Doctors Without Borders sections to be able to financially support themselves and contribute revenue to the movement.

This project will allow for more flexibility around the creation of new entities, and will allow for alternative and innovative approaches which do not fit into the current rigid structure.

In 2022, we achieved the following objectives or tasks:

• For the Doctors Without Borders Architecture document, we have completed mapping of all current entities into existing definitions, identifying gaps and redundancies, and their governance inter relationships.
• As a fundamental component of the Structures framework, we have developed draft proposals for defining/outlining Sections.
• A project on how we coordinate with International General Assembly representation was identified and presented on its status and stakes to the 2022 IGA held in June.
• Work around the executive outlook of Doctors Without Borders’s evolution, in terms of the number of new entities, their location and operational outputs, with the Core ExCom’s position on Movement Evolution has started.
• In October, the Full ExCom discussed the draft definition of Sections, which establishes Sections as foundational structures of Doctors Without Borders, and provided input on the funding principles for non-financially autonomous Sections. This was followed by a Core ExCom and IB briefing and discussion on core elements of the draft definition of Sections and their roles and responsibilities in November.