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 Doctors Without Borders / Médecins Sans Frontières (MSF)' 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, Doctors Without Borders 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.
We are aware that staff, association members, partners, donors and the communities we strive to help are observing us and our actions. They are looking at our capacity to change for the better. We welcome their scrutiny and we commit to being accountable for our failures, progress and achievements as we go along.Dr Christos Christou, Intl. President
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 Doctors Without Borders' 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.
A longer and more detailed version of this report was made available to all Doctors Without Borders staff. It is very much an internal document but we are making it available publicly here [link], while acknowledging that internal Doctors Without Borders jargon and assumed knowledge does not make it easy to read for an external audience.
We 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:
- 1: Management of abuse and inappropriate behaviour
There is clearly an unacceptable 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 and have indicated that there is insufficient trust in both reporting mechanisms and the management of complaints within Doctors Without Borders. Part of the answer to this lack of trust is the need to increase the ownership of these mechanisms at all levels of the organisation, by providing dedicated trained staff and financial resources, and by encouraging our diversity, equity and inclusion (DEI) and behaviour units to learn from each other’s expertise.
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 2020, we received 389 reports of abuse, including 41 complaints of discrimination.
To begin to address these shortfalls, we have created the following initiatives:
- A platform to share best practices and develop tools for managing cases of abuse, including developing clear and systematic messages on acceptable behaviour.
- A shared anti-discrimination learning programme, which can be adapted to local needs and will be suitable for all staff, both in our projects and in headquarters.
- An induction module on behaviour, as part of the general induction available to all new staff.
- An ‘Anti-Racism Project’, which aims to create anti-racism awareness and embed anti-racism practices into the way we operate.
- An intersectional booklet on behaviour which provides an overview of how we deal with behaviour issues.
- A range of other tools including posters, videos, briefing packages, trainings, workshops and case management guidelines.
At the same time, we need to ensure that our patients and the communities with whom we work are included in the prevention and detection strategies we are developing. So far, this has been a challenge, given the slow progress made on adapting messages and tools for each country. We are aware that we have not yet made sufficient efforts to communicate proactively with patients and communities regarding their rights and their options to bring grievances to Doctors Without Borders We also aim to decentralise prevention, detection, case management towards regional and local levels.
- 2: Staff reward, including remuneration and benefits
“In conversations with Doctors Without Borders staff members from across the globe, we are challenged frequently on rewards policies and on the different treatment experienced by different staff groups. People are right to challenge us – and to challenge Doctors Without Borders leadership – because we have much more to deliver.”
Dr Christos Christou, Doctors Without Borders International President
We are aware that Doctors Without Borders' 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 (ie ‘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 will launch the ‘Doctors Without Borders International Contracting Office’ (see section 4 for more details - LINK), which include the following initiatives:
- Our ‘Contracting and Rewards Strategy’ will define how we group staff to determine where and how they are contracted and rewarded. This will specify whether a staff member is paid a local salary, a global salary or a combination of the two, and will specify the rewards staff may receive in addition to their salary and core benefits. To design this strategy, we are receiving expert technical advice and comparing our system with that of other international NGOs.
- Our ‘Minimum Standards for Pay and Benefits’ will specify how local and global salary grids are developed, how they are benchmarked against labour markets, how they take into account the cost of living, and how they are adjusted and reviewed. We are also building a comprehensive database of Doctors Without Borders benchmarking data. Initial proposals for minimum standards for benefits include parental leave (for birth or adoption), paid leave and death and disability benefits.
- Our ‘Global Grading Framework’ is being designed with the help of external management consultants to ensure that positions are graded consistently, regardless of where the job is located.
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 addition, the impact on our workforce and wage bill will be significant. We expect design and stakeholder engagement to continue through 2022, with implementation starting at the end of 2022.
- 3: Exposure to risk – safety and security
“In some insecure contexts, the presence of certain profiles can increase the risk of detention, abduction and armed attacks, both for individuals and Doctors Without Borders teams as a whole. We know that there is a need to improve our overall understanding of exposure to risk and impact, including in highly insecure contexts and in relation to types of operations and categories of staff.”
Dr Christos Christou, Doctors Without Borders International President
This will involve developing consistent guidelines about which 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.
To address this issue, we held a workshop in Dakar in October 2020 to analyse the main issues around profiling and discuss the ethical questions it raises. These include: to what extent is it acceptable to practice this de facto discrimination? To what extent does profiling increase the security of individuals, teams and Doctors Without Borders as a whole? What are the consequences of profiling on staff members’ career paths and on our human resources policy? Further discussions in September 2021 concluded that profiling should be used solely for security management with the aim of mitigating risks for Doctors Without Borders staff and operations.
Doctors Without Borders is currently involved in a major two-year internal consultation process to define its medium-term vision; one of the areas explored is acceptance of risk. The issue of risk differential per categories of staff will be part of that conversation.
- 4: People recruitment and development
Doctors Without Borders' 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 centres and other Doctors Without Borders entities. With several of our operational centres reporting a shortage of experienced internationally mobile staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff.
Despite these challenges, there has been progress in the right direction. Our Dakar office is now the third largest recruiter in the Doctors Without Borders movement, after Paris and Brussels. We are certain that finding qualified staff from a broader range of regions will contribute to a better mix in our field teams and change the profile of our leaders and decision-makers in the medium and long term.
Data shows that our internationally mobile workforce has become more diverse over the past 10 years. In 2020, 50% of 3,326 full-time equivalents (FTEs) were from countries in the Global South – a two-fold increase on 2009.
However, internationally mobile staff from the Global North are more likely to be in senior management positions (including heads of mission), while those from the Global South are more likely to be in other roles. We need to look further at the reasons behind this.
The data also draws attention to other structural weaknesses – for example, only 33% of our project staff are female, and the percentage of our internationally mobile staff who are women recently fell for two consecutive years, from 46.2% in 2018 to 43% in 2020; again, we need to understand the reasons behind this.
To address these and other inequities, we have put in place the following initiatives:
- The ‘MSF International Contracting Office’ aims to address persisting inequities and administrative problems encountered by the 50% of internationally mobile staff who are resident in a country where Doctors Without Borders does not have a contracting office. Currently, these staff receive their contract from the operational centre which manages their assignment, which means they have no contract consistency if they are hired by another operational centre, hampering their mobility and access to jobs and causing differences in pay and benefits. From mid-2022, these staff will be provided with consistent contracts and better pay and benefits throughout their employment with Doctors Without Borders.
- Our learning and development platform, ‘Tembo’, aims to transform the way that our staff work, learn and develop themselves in order to maximise their skills, their talents and their positive impact on our humanitarian work.
- Our diversity, equity and inclusion repository and knowledge-sharing platform will facilitate a common understanding of DEI issues by developing a framework of accountability across Doctors Without Borders and facilitate a fluent exchange of information, insights, experiences and best practices between DEI practitioners in headquarters and in our projects.
We are also improving access to human resources information so that all staff can inform themselves about the policies and the rationale behind them, with the following initiatives:
- A new recruitment page on msf.org will mean that all vacancies will be accessible to anyone interested in working for Doctors Without Borders. To be launched in early 2022.
- A new site (rewards.msf.org) with information on ‘MSF as an employer’ and reward policies will be accessible to all Doctors Without Borders staff (including those who have no Doctors Without Borders email address). To be launched in mid-2022.
- A new HR Portal with all policies and guidelines will be accessible to staff with access to an Doctors Without Borders computer. To be launched in early 2022.
- 5: Communications and fundraising
For many years, people working in communications and fundraising across Doctors Without Borders have had animated discussions on how to represent our work, our staff, our patients and their communities in a way acceptable to everyone. There have been regular challenges from within and outside Doctors Without Borders about materials perceived as insensitive, culturally inappropriate, failing to display the true diversity of our staff, or failing to show the agency of patients and members of their communities. In worst-case scenarios, some materials have been perceived as reinforcing white saviourism, neo-colonialism and racism.
We fully intend to address these issues, while being aware that the concept of sensitive communication or representation varies from one society to the next and between languages. We need to find the right balance and refrain from imposing a single norm across Doctors Without Borders. At the same time, we need to ensure that our communications and fundraising staff can continue to release hard-hitting and truthful accounts of suffering and disaster when producing communication tools and campaigns, while seeking to do so in ways that avoid stereotyping and labelling individuals or communities in ways that could be offensive or could contribute to colonial, racist or other discriminatory tropes.
We have launched the following initiatives to make sure that our public communications embrace the principles of diversity, equity and inclusion:
- A dedicated taskforce was set up in April 2021 to work on the application of DEI principles to all of our communications and fundraising strategies, products and materials, including aspects related to racism and racial discrimination, as well as to gender, LGTBQIA+, people with disabilities and other forms of discrimination. It will adapt existing guidelines, produce a new guidance document, and organise and systematise the sharing of knowledge and experience around DEI to promote good practice. Once the guidelines are finalised in early 2022, we will use them as the basis for training and induction materials.
- An internal ’sounding board’ group will be active from January 2022 to look at upcoming communications products and campaigns from a DEI perspective.
- An online portal on DEI, available to all communications and fundraising staff, will be launched in early 2022.
- A project has been set up to review the 180,000 photos and videos hosted in our audio-visual media database, some of which date back 50 years. We will make sure that they comply with privacy and copyright regulations and we will critically review, annotate, archive or remove items which are outdated, sensitive or detrimental to a positive representation of our staff, communities, patients and activities.
- 6: Standards of care for the patients and communities with whom we work
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.
In early 2021, our medical directors began implementing the ‘Improving Collaborative Leadership’ (ICL) initiative, which aims to review interactions on medical issues within the Doctors Without Borders movement. DEI will also be integrated into our consultation processes with patients.
- 7: Executive governance and representation
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.
Already, representation at the highest levels of the Doctors Without Borders movement is shifting: in 2020 and 2021, three new non-European regional sections (Doctors Without Borders Latin America, Doctors Without Borders South Asia and Doctors Without Borders East Africa) became voting members of Doctors Without Borders' highest executive platform, bringing new voices to our governance structure, while Doctors Without Borders West Africa obtained the right to run operations.
Conclusion: A fundamental shift in our culture
We must also acknowledge the initiatives that are happening across the Doctors Without Borders 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, Intl. 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.