Tackling institutional discrimination and racism within Doctors Without Borders

Addressing issues around abuse have been a high priority for MSF leadership. In the last two years, increased attention and effort have been put into tackling these issues. We continue to collect data on behavioural complaints in MSF. A breakdown of the number and type of complaints we receive (made by staff, patients and their caretakers, community members, and others), and those complaints that are confirmed each year), can be found here. While each year generally sees incremental increases in the numbers of complaints received, we know that there is more work to be done to enable anyone affected by, who witnesses, or has concerns about abuse to report it.

MSF continues to make efforts to create an environment free from abuse and harm for our staff and for patients, their caretakers, and the communities in which we work. A focus on prevention and detection of abuse, alongside making reporting mechanisms accessible and inclusive, are critical for this work. When complaints about abuse are made, ensuring that there are sufficient, well-trained persons in place to address them is also critical to illustrate our commitment to take allegations of abuse seriously, to address them in a timely manner, and take responsive and remedial action, should abuse be found to have occurred.
 
Over the last two years, we have moved forward in our efforts to prevent, detect, and address abuse by:

• Hiring a Safeguarding Coordinator – at the international level, an International Safeguarding Coordinator (ISC) was hired and started work in 2023. The ISC works to define and advance safeguarding work within MSF, working with all stakeholders across the movement. This includes defining what actions need to be taken by MSF to continuously improve our ability to prevent and detect abuse, enable reporting of abuse, ensure allegations of abuse are addressed, and ensure that there are trained people who can address allegations of abuse in a timely and professional manner. The ISC also coordinates platforms for behavioural leads in MSF (both in operations and partner sections).
• Working to create a pool of investigators – approving the establishment of a global pool of investigators for administrative investigations of allegations of abuse in the countries and projects where we operate or have presence. 
• Common case management mechanism – a common case management mechanism has been designed to respond to concerns or reports of serious allegations of abuse spanning multiple MSF entities. The mechanism includes clear processes to be activated, to address such cases efficiently.  
• Field based positions – in Bangladesh and Afghanistan we’ve engaged staff to work on prevention, detection, strengthening reporting, and addressing abuse, as well as rolling out a safeguarding risk assessment in certain locations. 

In addition, many activities require ongoing and continuous work. For example, awareness-raising about expected behaviour and how and where to raise complaints about abuse; training staff; training managers on how to welcome complainants; risk assessments; safe recruitment and performance management; strengthening efforts on DEI; focusing on patient centred approaches; case management and investigation; improving access to reporting mechanisms (including for patients and communities), and understanding barriers to reporting.

“We have listened to feedback from our staff, and we are striving towards more equity and better transparency on how people are remunerated for their work. Through the Rewards Review, we carried out an in-depth analysis of our existing policies and process, and developed proposals on what needs to change. This change is complex and ambitious, but we can’t afford not to succeed.” 

- Dr Christos Christou, Doctors Without Borders International President 

We are aware that MSF’s salary and reward policies and processes do not align with our ambition for a diverse global workforce. They do not adequately support our evolving operational and organisational requirements, lead to inconsistencies, hinder mobility, and are perceived as inequitable by many of our staff. To address these inequities, over the last two years we’ve taken the following actions:

• A review of our policies and processes – the Rewards Review – was carried out to systematically analyse MSF’s existing approach to pay and benefits. Between 2021 and 2023, this review involved over 4,000 staff, who provided input over 450 staff engagement sessions. The review also analysed data on how our workforce has evolved, how staff are paid today, and how MSF pays staff compared to other employers in similar contexts.  
• In April 2023 the results of the review were presented to the ExCom and identified problems, including: policies and practices that have not evolved with trends; unacceptable differences in pay and benefits packages; inconsistencies in valuing jobs and staff support; and inadequate HR governance and accountability. 
• In May 2023, the executive leadership of MSF agreed to significant changes to MSF’s rewards policies to address these problems, including a set of core benefits for all staff; minimum standards for pay; a consistent definition of living wage with adjusted methodology; a consistent benchmarking approach; two new staff groupings – mobile staff and country-based staff – to replace the existing, outdated groups; and a framework to ensure that jobs and functions are graded consistently across the organisation.

These are very significant changes that will take several years to fully roll-out. However, key improvements for some staff have already been implemented from October 2023 including: 

• The removal of the indemnity (the practice whereby mobile staff received an indemnity payment instead of a salary for the first 12 months of working with MSF). 
• The launch of the International Contracting Office (ICO) to provide a consistent contracting experience, aligning pay and benefits for staff who don’t have an MSF contracting office in their own country (see more under section 4, People recruitment and development). 
• The set up of the MSF International Retirement Savings Plan for ICO contracted staff. 

Working in contexts of violence and conflict have been an integral part of MSF’s operations since our inception. Ensuring the safety and security of our staff is one of our biggest priorities, and challenges. We choose the areas where we run our projects, and in doing so, we seek to anticipate, prevent, and address security threats within projects.

Human resources restrictions for staff working in our programmes based on non-professional criteria – gender, ethnicity, physical appearance, religion, age, nationalities, etc – can be imposed on MSF by external organisations, such as states or armed groups, or decided by MSF. This is a compromise in our preferred way of working and we seek to limit the use of these restrictions to a minimum.  
 
When decided by MSF, the two rationales on HR restrictions are:

• the safety and security of our teams and our operations; and 
• where required, to ensure our access to communities.  

HR restrictions processes, decision making, and implementation are internal to each OD, but the processes are shared amongst ODs. Furthermore, the type and location of restrictions are also shared and reviewed once a year at the RIOD; each OD is responsible to update this common tool. 

Generally speaking, responsibility for safety and security measures for our staff lie principally with the ODs, with whom the bulk of this work rests. Therefore, the remit of the Core ExCom’s plan is to assist with the coordination of these measures.

MSF’s existing staffing model has led to unequal access to recruitment and career development opportunities. This contributes to a lack of diversity in team composition; poor gender ratios among programme staff; difficulties in access to coordination and management positions for locally hired staff; and has resulted in over-representation of staff of Western origin in senior and 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, retaining and developing our staff. There is no single organisational workforce strategy, and our principles are applied differently across our various operational directorates and other MSF entities. With a number of our operational directorates reporting a shortage of experienced international mobile staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff internationally and locally, and reversing the deteriorating gender ratios among mobile staff.  

To address these and other inequities, over the last two years, we have achieved the following objectives: 

• Contracts for staff located without an MSF office – an International Contracting Office (ICO) was established, and in October 2023 the ICO issued its first contracts to mobile staff who don’t have an MSF contracting office in their own country and ran the first payroll. The ICO provides a consistent contracting experience, aligning pay and benefits for these staff regardless of the operational directorate they work for. It also provides a seamless support during their career with MSF and one single point of contact for contracting purposes. 
• Delocalised headquarters – the International Office and a number of the ODs have increasingly delocalised positions, and even entire departments, away from their traditional European bases. This means that vacancies for headquarters positions are being opened across regional hubs, including in Nairobi, Amman, Dakar, Dubai, Bogotá and Buenos Aires, increasing diversity in some of those positions and departments and HQs in general.
• Job vacancies page – a recruitment page on msf.org was launched, so that job vacancies across many MSF offices are accessible to anyone interested in working for MSF; 1,685 vacancies were published since the site’s launch in April 2022 until the end of 2023.
• Accessible employer policies site – a new site (rewards.msf.org) with information on ‘MSF as an employer’ and reward policies was launched in 2022, accessible to all MSF staff (including those without an MSF email address and therefore no access to the organisation’s intranet). 
• Human resources portal – a human resources portal was launched, and all HR policies and guidelines were made accessible in Arabic, English, French and Spanish to staff with access to an MSF computer; for staff without an MSF log in, we have made policies available on the rewards page on msf.org. 
• Improved data reporting and analysis – the 2022 MSF Staff Data and Trends Report, published in June 2023, included improved analysis and more detailed reporting on workforce make-up, to help us improve our understanding of our workforce and how it’s evolving. ODs are using this information to inform approaches to recruitment and development through the Recruitment and Career Management Platform.

“We are committed to respecting the dignity and agency of the people we treat, and recognise that this is fundamental to fulfilling our mission to bear witness and speak out about human suffering. We are working to improve our guidelines, standards, and policies, and we are also shifting our own mindset.”

- Dr Christos Christou, Doctors Without Borders International President 

With MSF communication and fundraising materials providing the public face of the organisation, calls to ensure that these materials respect and demonstrate 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 MSF. While there is still work to do, there has been significant progress made towards achieving the objectives set for Communications and Fundraising in tackling Diversity, Equity and Inclusion (DEI) issues. They include:

• DEI guide for communications – a DEI guide was produced by the dedicated taskforce that advises MSF teams on the creation of more respectful, ethical and inclusive public communications productions that accurately represent our staff, patients and the communities with whom we work in a dignified way. A course on using the DEI Guideline has been developed in English, French and Spanish and has been published on our inhouse training platform. 
• DEI language guidelines – starting in mid-2021 and continuing into 2022, “Guidelines to equitable, respectful and inclusive language in MSF communications” were published in languages including English, French, Arabic, and Spanish. These guidelines, which complement the DEI guide, help MSF content producers, editors and disseminators use appropriate terms to describe people, crises and contexts. Other, topic-specific guidelines – such as on disability – were produced and disseminated in 2022 and 2023.
• DEI-focused positions – a temporary DEI Guideline Roll-out Coordinator position was recruited at the end of 2022 to facilitate the rollout and training on the guide, with a fundraising professional also trained as a DEI facilitator identified. This role has since ended given the roll-out had been completed as envisaged. 
• Online DEI hub – the DEI knowledge hub for MSF Communications and Fundraising Professionals, also known as Ubuntu, was also launched in September 2022. The aim of this online internal hub is to inform and inspire communications and fundraising teams on DEI matters and link to existing internal and external resources on the topic. 
• Feedback group – a Peer Feedback Group was created to provide feedback on the sensitivity of packages, with a large group of volunteers from across the movement reviewing communications content and flagging concerns related to portraying patients/communities in an undignified manner, advancing stereotypes, and/or the inclusion of hero/white saviour narratives. The Peer Feedback Group’s highly valuable work has since been promoted further to ensure support is sought early in e.g. campaign production development processes. 
• Media database review – An audio-visual media database content review was launched in 2021, with a revision of photos being completed in August 2023. More than 150,000 pictures were reviewed to identify any imagery that did not comply with our ethical standards and DEI commitments, with 114,000 being reviewed twice; about 12,500 photos were flagged and 2,500 have since been removed from view and use. 
• Pledge to tackle problematic imagery – in June 2022, the Full DirCom 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.
• External advice and recommendations – Following the Full DirCom’s pledge, and based on the work of the database review, a series of workshops with two advisory panels – one with medical and other functional experts from inside MSF and another with academics and professionals from outside MSF – were organised to gather their advice and recommendations on audio-visual practices, with a report being produced. 
• Audio-visual ethical framework – from the report’s recommendations, funding was secured for a position to develop, disseminate and roll-out (including through appropriate training) a new audio-visual ethical framework (guidelines) for MSF. This expert was identified and started work in January 2024. 
• Photographer contracts proposal – After being alerted that images that do not comply with our DEI commitments taken previously in MSF structures remain available for distribution by photographers or through photo agencies, contracts for photographers have been collected and reviewed, and proposals for new clauses and contracts have been produced. 

MSF has made the commitment to systematically integrate diversity, equity and inclusion principles in deciding where and how we respond in the countries we work and in setting standards of care for the communities we work in. This commitment puts the focus on the people we serve, while ensuring our staff practice an inclusive and non-discriminatory provision of care.  

We are working to apply these principles to our existing medical policies, activities, and initiatives, based on three key pillars of work: 

• integrating diversity, equity and inclusion action points in medical guidelines and policies
• implementing a patient/person/community-centred approach and ensuring programme choices and project designs include a diversity, equity and inclusion lens, and
• developing shared accountability through identification of relevant indicators and ensuring their application for proper monitoring and evaluation of progress.

Over the last two years, work on this area has included:

• Patient Charter – In 2023, a patient charter was developed in consultation with internal and external experts as well as patient representatives, and finalised in collaboration with the International Board. Based on the provision of effective, safe, and equitable healthcare in the contexts in which we work, the Charter’s principles include Dignity and Respect; Safe healthcare and Protection; Access; Information; Participation and Consent; Privacy and Confidentiality; Feedback and Complaints Procedures. These principles today serve as a guide for each operational directorate to implement and adapt according to the cultural and context particularities of their project settings. 
• Protecting patient data – Work on implementing a patient data protection strategy has continued, which ensures the protection of patient health data centred on patient rights and medical confidentiality. Critical in ensuring protection is in informing patients on how their medical information is used and what mechanisms are available to them in case of concern.  As part of this effort, a patient health information notice form has been finalised and is being systematically included in our facilities. 
• A list of quality-of-care indicators – A library of quality-of-care indicators was developed and approved by the DirMed and MedOp platforms, to be used by the various intersectional medical platforms and ODs in their data collection sets. This should help in the monitoring of the levels of quality of care achieved in a given time period. In addition, patient safety indicators are also being standardised. 
• Coherent optimisation of activity data – A health data strategy has been developed under the DirMed platform that aims to optimise and secure the use of medical activity data (number of consultations, type, etc), providing a coherent approach across ODs. The strategy takes a data minimisation approach, which helps ensure quality monitoring, that unnecessary data is not collected, and that patient information is used optimally.  
• Quality medical products review – In ensuring we are providing quality medical and healthcare products, a review of the work of the Quality Assurance team was undertaken, with areas of progress and further need for development highlighted. Work on this is coordinated between the International Medical Quality Products and Publication team, supply centres and the Global Procurement Unit, amongst others. 
• Mutual Accountability Revision process – a revision process of the mutual accountability mechanism – the tools and methodologies by which MSF measures the quality and relevance of our activities – was launched in 2022, to review the typology indicators used, the governance process, the quality of analysis, and to ensure that diversity, equity and inclusion is included in reflections. An important part of this revision is finding with which teams and stakeholders need to be engaged and consulted to capture relevant information, data and reporting.  

The history of MSF’s founding and evolution over the last 50 years has meant that the power and decision-making structure within MSF has been concentrated in Europe. In recent years, we have questioned how this decision-making power should be distributed across the MSF movement. Since the creation of the West and Central Africa operational directorate in 2019 – which granted decision-making on where and how MSF operations are run for the first time outside of Europe – this has slowly begun to change. However, the decision-making entities in MSF continue, for the most part, to lie within Europe. 

To address this, we’re critically evaluating and addressing our structure. We’re doing this through a project which will allow us to maintain a solid and accountable system of governance, but which would provide more flexibility in having decision-making entities established outside of Europe. 

Up until the end of 2023, the Full ExCom developed a vision document on how to manage the number and location of current and future entities, always keeping how these entities will benefit the work of MSF at the core of their decisions. 

In 2020, the deep inequities exposed by the COVID-19 pandemic converged with powerful movements for racial equality around the world. In parallel, a multitude of grassroots voices denounced MSF’s own struggle to tackle racism and discrimination. 

Despite years of raising awareness and efforts to address these issues, we acknowledged that progress had not been fast enough. In July 2020, recognising the pain and anguish expressed by many of our staff and patients, MSF made a public commitment to tackle discrimination and racism within our organisation. 

Almost 18 months into the process, it is time to provide an honest update of where we are and how much more we need to do.

The information provided here is not an exhaustive list of all initiatives but summarises some of the main movement-wide progress based on priorities agreed by MSF’s Executive Committee. There are countless initiatives being carried out in our projects and headquarters that are not covered in this update. This should serve as a baseline for future reporting on these issues.

We remain committed to “lead the way for the radical action sought after and demanded by our associations” and identified the following seven areas as needing urgent and concrete action.

Conclusion: A fundamental shift in our culture

“We must also acknowledge the initiatives that are happening across the MSF movement. These initiatives aim to ensure that all voices are heard, by creating DEI councils, engaging in associative and executive meetings and discussions, launching surveys and reports, and using external consultants and agencies to help remove possible bias in collecting views and developing the way forwards. We need local solutions as well as global approaches.” - Dr Christos Christou, MSF International President

The processes we have started are not about making small adaptations here and there. Instead they amount to a deep cultural change that will influence all levels and all activities of our organisation. They will bring about changes that will make a tangible difference to the daily lives of our staff, our patients and their communities. We cannot underestimate the scale of the challenge that a true culture shift represents. While there has been progress in the right direction, we know that we still have a long way to go.  

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.

International Board (IB) – is the Board of MSF International. It acts on behalf of, and is accountable to, the International General Assembly (IGA). Headed by the International President, the board is composed of both elected and co-opted members. 

Executive Committee (ExCom)
Full ExCom – executive decision-making body composed of the directors general of the 24 MSF sections and the International Medical Secretary; chaired by the International Secretary General.
Core ExCom – core executive decision-making body composed of the directors general/executive directors of the six operational directorates, the directors general of two elected partner sections, the International Medical Secretary, and chaired by the International Secretary General.

Operational Directorates (ODs) – the six directorates which decide where, what, when and how MSF responds to medical and humanitarian needs in the countries we work; they run independently of each other and are based in Amsterdam, Barcelona, Brussels, Geneva, Paris, and a West and Central Africa OD based in Abidjan, Cote d’Ivoire.

RIOD – originally, in French/English, Réunion Internationale de Operational Directors. A platform consisting of the directors of operations of the six Operational Directorates within MSF, chaired by the International Operations Humanitarian Representation Coordinator.  

International Directors’ Platform for Human Resources (IDRH) – The platform composed of the directors of human resources of the six operational directorates and two elected section HR directors, chaired by the International Human Resources Coordinator.

Directors of Communication platform (DirCom) 
Full DirCom – platform composed of the directors and heads of communications of each section of the movement. Chaired by the International Communications Coordinator.
DirCom5 – the core decision-making body for communications, composed of the directors of communications for the six operational directorates, plus directors of communications elected from two partner sections. Chaired by the International Communications Coordinator.

Directors of Fundraising (DirFund) – platform composed of five elected heads of fundraising from MSF sections or branch offices, chaired by the International Fundraising Coordinator.

Medical Directors’ platform (DirMed) – composed of the medical directors of the six operational directorates, the Medical Director of the Access Campaign, the International Medical Coordinator, and International Medical Secretary.

Medical and Operational Directors platform (MedOp) – composed of members of the DirMed and RIOD platforms: the medical and operations directors of the six operational directorates, the executive and medical directors of the Access Campaign, the International Medical Coordinator, and the International Operations Humanitarian Representation Coordinator. Chaired by the International Medical Secretary.