Responsible Behaviour - Statement 2022 - Médecins Sans Frontières(MSF)/Doctors Without Borders

Doctors Without Borders/Médecins Sans Frontières (MSF) promotes a working environment free of harassment and abuse. Our leadership has unequivocally committed to reinforce mechanisms and procedures to prevent and address abuse and harassment. All staff are expected to abide by the MSF movement’s Behavioural Commitments and our guiding principles as stipulated in our Charter.

The integrity of our organisation is upheld by the good conduct of each individual staff member, in any location, with full respect for the communities we serve. For us, this means not tolerating any behaviour from our staff that exploits the vulnerability of others, or of employees taking advantage of their position for personal gain.

Grievance and whistle-blowing mechanisms

Procedures, including grievance mechanisms, are in place to encourage prevention, detection, reporting, and management of all types of misbehaviour, harassment and abuse. Through these mechanisms, all staff members are encouraged to report inappropriate behaviour or abuse either through their management line or through specific reporting channels outside any hierarchical lines, using dedicated email addresses. Victims or witnesses in the communities where MSF works are likewise encouraged to report misconduct to us so that allegations can be properly addressed.

Broad awareness activities are carried out to inform all staff of the mechanisms available to them to report abuse. This information is shared through specific communications, including in printed staff manuals, and is conveyed in briefings, field visits and trainings. Moreover, e-briefings and learning modules related to behaviour and management of abuse are regularly updated and improved.

There is a range of ongoing work in this area that has been taking place across the MSF movement in recent years. Examples include:

Creating new positions and/or increasing staff support to provide training, field visits and investigation on these issues.
Undertaking workshops and other forms of consultation with staff to assess the problem and the steps needed to address it.
Revising, promoting and strengthening guidance provided to staff on how to report harassment, abuse or exploitation.
Reinforcing awareness at the patient and community level where we have operations
Improving data-gathering and sharing across the MSF movement.

Managing misbehaviour cases confidentially

MSF aims to ensure that these situations are addressed with the utmost confidentiality, to create an environment where people feel they can safely file complaints, without fearing for their safety, their job, or their confidentiality.

Our first priority when misbehaviour is reported is the safety and health of the potential victims. Immediate attention is given to provide support, which can include psychological and medical care, and securing legal assistance.

MSF always respects the victim’s decision to bring – or not – a matter to justice. In the event of sexual abuse against minors, MSF’s policy is to report the case to judiciary authorities depending on the child’s best interests and availability of such procedures.

Key challenge: reducing barriers to reporting

2018 update

While the 2018 figures show an increase in the reporting of incidents of unacceptable behaviour compared to 2017, we still believe this picture to be a significant underestimate – this is likely due to a combination of challenges around both under-reporting and data gathering.

In 2018, MSF had almost 65,000 staff working in field. We saw a significant increase in the number of alerts and complaints recorded in 2018, with a total of 356 grievance complaints made, up from 182 in 2017. This figure relates to alerts and complaints made on the field but does not cover headquarter offices. We hope that these figures are an indication that an increased focus on the issue has encouraged more people to come forward.

Of those complaints, after investigation, 134 were confirmed as either situations of abuse or of inappropriate behaviour (83 in 2017). This includes 78 cases which were qualified as abuse, compared to 61 cases of abuse in 2017. (This covers many forms of abuse: sexual abuse, harassment and exploitation; abuse of power; psychological harassment; discrimination; physical violence.) A total of 52 staff members were dismissed for all forms of abuse in 2018 (58 dismissals in 2017).

Of the 78 cases of abuse, 59 were cases of sexual abuse, harassment or exploitation, up from 32 in 2017. Thirty-six staff were dismissed as a result of those cases in 2018 up from 20 in 2017.

There were also 56 confirmed cases of inappropriate behaviour, up from 22 in 2017 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standard or affecting team cohesion; and the use of substances).

We continue to urge staff, patients or anyone else who comes into contact with MSF to report any incidents of unacceptable behaviour which they come across.

NOTE ON CHANGES TO THE FIGURES: Due to improved data collection and compilation, MSF has updated its figures for 2017. As a result, the total number of complaints for 2017 is found to have been higher than previously reported: 182 as opposed to 146; the number of confirmed cases in 2017 has also risen slightly. Please note that some cases in 2018 are still being investigated, so the overall figures may change slightly.

2019 update

MSF continues to face a challenge of under-reporting when it comes to responsible behaviour. Since 2017, we have seen an increase in the number of complaints being reported, which is an encouraging sign that MSF’s reporting mechanisms are being more widely used. While the total number of reports has dipped slightly (by 10%) between 2018 and 2019, we believe this is primarily due to a large number of historical cases having been reported in 2018 – likely a result of the increased levels of communication on this issue, both internally and externally. We need to continue working to improve levels of reporting, especially among groups which have tended to be under-represented when it comes to making complaints – including locally-hired MSF staff, patients in MSF projects, and their carers. 2019’s figures have showed increases in the number of reports received from these groups, which is encouraging, though we acknowledge that there is still a long way to go.

In 2019, we had approximately 65,000 individual staff movement-wide, of more than 90 per cent were working in the field. We saw a total of 322 grievance complaints made, down from 356 in 2018. This figure relates to alerts and complaints made in the field but does not cover headquarter offices.

Of those complaints, after investigation, 154 were confirmed as either situations of abuse or of inappropriate behaviour (134 in 2018). This includes 104 cases which were qualified as abuse, compared to 78 confirmed cases of abuse in 2018 (This covers many forms of abuse: sexual abuse, harassment and exploitation; abuse of power; psychological harassment; discrimination; physical violence.) A total of 57 staff members were dismissed for all forms of abuse in 2019 (52 dismissals in 2018).

Of the 104 cases of abuse, 63 were cases of sexual harassment, abuse, or exploitation, up from 59 in 2018. 37 staff were dismissed as a result of those cases in 2019 up from 36 in 2018.

There were also 50 confirmed cases of inappropriate behaviour, down from 56 in 2018 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standard or affecting team cohesion; and the use of substances).

While the overall number of complaints is down by 10% compared to 2018, it is encouraging to see an increase in the number of complaints being made by groups that have been particularly under-represented: The number of complaints made by national staff increased from 128 in 2018 to 144 in 2019. This is a step in the right direction, although national staff continue to be under-represented, accounting for only 45% of all complaints despite making up more than 90% of MSF’s field-based workforce. The number of complaints made by MSF’s patients and their carers has also increased, although it must be noted that this was from a very low base: from 13 in 2018 to 19 in 2019 (an increase of 46%). Underreporting from patients and their carers clearly remains an area where we must continue to focus, to ensure that mechanisms are accessible and understood. During 2019, a number of measures were taken to address this, including the development of staff training modules and workshops to get input from patients and carers.

The reasons for under-reporting are similar to those found in society at large, including the fear of not being believed, prevailing stigma, and possible reprisals. This is all the more acute in many crisis settings where MSF operates, such as conflict areas, where there is often a general lack of protection mechanisms for victims, a high level of generalised violence and impunity, and where populations may be highly dependent on external assistance. The size, turn-over and diversity of our staff require a continued effort to inform and create awareness about MSF’s policies on harassment and abuse, as well as all mechanisms available for reporting any abuse or harassment.

2020 update

In 2020, MSF had more than 63,000 individual staff movement-wide. We saw a total of 444 complaints made across our staff working in medical and humanitarian projects in the field (389 complaints) and across international headquarter offices (55 complaints). Further details below break down field and headquarters cases separately, as they are not necessarily comparable in terms of terminology and reporting processes.

The overall number of complaints received increased by 22 percent in 2020 compared to 2019. While MSF continues to face a challenge of under-reporting of behaviour incidents, this increase can be seen as a sign that MSF is starting to address this long-term problem. It indicates that complainants and witnesses have increasing confidence to speak up, and that there is growing awareness of the various reporting mechanisms and channels that have been reinforced and put in place.

The pandemic has led to a reduction in face-to-face activities to prevent unacceptable behaviour, however significant effort has been put towards virtual training. The total number of staff trained to deal with behaviour issues actually increased compared to 2019.

Despite these improvements, under-reporting continues to be an issue. Of particular concern is the limited (if increasing) number of complaints from patients, care givers and community members. This indicates the need to focus on prevention and to develop adapted community complaints mechanisms for these groups.

Complaints from our projects in the field

Over 90 per cent of MSF staff (57,429 individuals in total) in 2020 were working in the field. A total of 389 complaints were made relating to this category of staff, up from 318 in 2019.
Of those complaints, after investigation, 150 were confirmed as either situations of abuse or of inappropriate behaviour (156 in 2019). (Please note that 15 reported complaints for 2020 remained open at the time these figures were compiled.)
This includes 82 cases which were qualified as abuse, compared to 106 confirmed cases of abuse in 2019 (this covers different forms of abuse: sexual abuse, harassment and exploitation; abuse of power; psychological harassment; discrimination; physical violence). A total of 37 staff members were dismissed for all forms of abuse in 2020 (55 dismissals in 2019). Depending on the severity of the case, other sanctions were also issued, such as suspension, demotion or formal written warnings.
Of the 82 confirmed cases of abuse, 55 were cases of sexual harassment, abuse, or exploitation (SEAH), compared to 63 in 2019. Twenty-eight (28) staff were dismissed as a result of those SEAH cases in 2020 (40 in 2019).
The other confirmed cases of abuse consisted of: psychological harassment (14 confirmed cases); abuse of power (8 confirmed cases); physical violence (3 confirmed cases); and discrimination (2 confirmed cases).
There were also 68 confirmed cases of inappropriate behaviour, up from 50 in 2019 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standards or affecting team cohesion; and substance use).

We have continued to see small but notable increases in the number of complaints submitted by previously under-represented groups, though there remains a lot of work to be done:

The total number of complaints submitted by locally hired staff increased again in 2020 to 172 (up from 144 in 2019). While this may be a marginal success in improving awareness and trust for colleagues to submit complaints, there is still more to be done considering that locally hired colleagues account for 80 per cent of the MSF work force.
The total number of complaints submitted by patients, caregivers, community members and other external parties showed a very slight increase, to 23 in 2020 (up from 20 in 2019). Considering that MSF undertakes millions of medical consultations each year in all our various projects, along with many other forms of contact with the communities we assist, this is very likely to be significant under-reporting. Existing complaint mechanisms need to be further adapted and improved to better reach patients and communities in individual project locations, especially given the extremely vulnerable position of many of those people whom MSF assists.

Complaints from our offices worldwide

2020 is the first year for which MSF has compiled complaints from our offices around the world, in addition to the data gathered from our medical projects in the field. Around 10 per cent of the total MSF workforce is based in these international offices.

As we have noted in previous years, the absence of these figures has led to a significant gap in our data. There is no prior year comparison. It is also worth noting that, while efforts have been made to standardise reporting, this data relates to a large number of different legal and HR processes, and so may not yet be fully harmonised.

Out of 37 headquarter offices (non-operational entities) which accounted for 5,596 staff (10 per cent of MSF workforce) in 2020, 55 cases were reported either through management lines or office-specific behaviour reporting mechanisms.
After investigation, 38 cases were confirmed as either abuse (20) or inappropriate behaviour (18).
Out of these cases, 20 people were either dismissed or received other sanctions, such as formal warnings, depending on the severity of the facts.

Achieving and maintaining a work environment free from abuse and harassment is an ongoing endeavour, for which we are all responsible. We also commit ourselves to do no harm to vulnerable people we are striving to help.

We continue to urge staff, patients or anyone else who comes into contact with MSF to report any incidents of unacceptable behaviour which they come across.

2021 update

In 2021, nearly 63,000 individuals worked for the MSF movement worldwide. During that year, we saw a total of 539 complaints relating to either abuse or inappropriate behaviour made across the MSF movement. Of these, 490 were related to our medical and humanitarian projects, and 49 related to our international headquarter offices. Further details below break down project and headquarters cases separately, as they are not necessarily comparable in terms of legal and reporting processes.

The overall number of complaints received increased by 21 percent in 2021 compared to 2020. While MSF continues to face a challenge of under-reporting of behaviour incidents, especially from patients, their carers, and the communities we assist, this increase can be seen as a sign that MSF has made further progress in addressing this long-term problem – and that awareness and confidence in our reporting mechanisms and channels is continuing to grow.

Complaints from our projects:

Around 90 per cent of MSF staff (around 57,000 individuals in total) in 2021 were working in MSF’s projects. A total of 490 complaints were made relating to this category of staff, up from 389 in 2020.
Of those complaints, after investigation, 158 were confirmed as either situations of abuse or of inappropriate behaviour (149 in 2020).

This includes 102 cases which were qualified as abuse, compared to 82 confirmed cases of abuse in 2020 (this covers different forms of abuse: sexual exploitation, abuse and harassment (SEAH); abuse of power; psychological harassment; discrimination; and physical violence).
A total of 54 staff members were dismissed for all forms of abuse in 2021 (40 dismissals in 2020). Depending on the severity of the case, other sanctions were also issued, such as suspension, demotion, formal written warnings or mandatory trainings.
Of the 102 confirmed cases of abuse, 67 were cases of SEAH, compared to 55 in 2020. 33 staff were dismissed as a result of those SEAH cases in 2021 (28 in 2020).
The other confirmed cases of abuse consisted of: psychological harassment (9 confirmed cases); abuse of power (16 confirmed cases); physical violence (4 confirmed cases); and discrimination (6 confirmed cases).
There were also 56 confirmed cases of inappropriate behaviour, down from 67 in 2020 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standards or affecting team cohesion; and substance use).

We have continued to see some increases in the number of complaints submitted by previously under-represented groups, though there remains a lot of work to be done: The total number of complaints submitted by locally-hired staff increased again in 2021 to 262 (up from 172 in 2020). This represents an increase of 52% year-on-year, and may be seen as an encouraging trend. However, more still needs to be done as locally-hired colleagues account for around 90% of the global workforce, but are responsible for only around half of complaints made.

The total number of complaints submitted by patients and their carers showed a very slight increase, to 23 in 2021 (up from 20 in 2020). The number submitted by “other” external parties – a category which includes suppliers, media, other actors, community members, partners, ex-MSF staff, non-MSF contracted staff and MSF association members – saw an increase of nearly 150%, to 67 (from 27 in 2020). It is concerning that the number of complaints from patients and their carers has remained so low. This is a clear indicator that more needs to be done to reach out to and empower patients and community members, by making them aware of their rights to hold MSF accountable for any abusive and inappropriate behaviour.

Another notable point is that, across all complaints from both MSF staff and people outside the organisation, there have been a relatively low number relating to discrimination and racism – despite ongoing movement-wide efforts to address these issues. A total of 32 complaints relating to discrimination were received in 2021, down slightly on the total of 41 in 2020. This suggests that more efforts on diversity and inclusion need to be integrated into mainstream channels of awareness raising on behaviour issues.

Complaints from our offices worldwide

Since 2020, MSF has also compiled complaints from our offices around the world, in addition to the data gathered from our medical projects. Around 11 per cent of the total MSF workforce is based in these international offices.

While efforts have been made to standardise reporting, this data relates to a large number of different legal and HR processes, and so may not yet be fully harmonised.

Out of 38 headquarter offices, 49 complaints were received in 2021 (down slightly from 55 in 2020, across 37 offices).

Of these, 25 were confirmed, with 19 cases related to abuse and 11 to inappropriate behaviour.1 This compares to 20 confirmed cases of abuse and 18 of inappropriate behaviour in 2020.

Overall, 13 sanctions or dismissals were given in 2021, compared to 20 in 2020.

Complaints from our projects in the field

Over 90 per cent of MSF staff (57,429 individuals in total) in 2020 were working in the field. A total of 389 complaints were made relating to this category of staff, up from 318 in 2019.
Of those complaints, after investigation, 150 were confirmed as either situations of abuse or of inappropriate behaviour (156 in 2019). (Please note that 15 reported complaints for 2020 remained open at the time these figures were compiled.)
This includes 82 cases which were qualified as abuse, compared to 106 confirmed cases of abuse in 2019 (this covers different forms of abuse: sexual abuse, harassment and exploitation; abuse of power; psychological harassment; discrimination; physical violence). A total of 37 staff members were dismissed for all forms of abuse in 2020 (55 dismissals in 2019). Depending on the severity of the case, other sanctions were also issued, such as suspension, demotion or formal written warnings.
Of the 82 confirmed cases of abuse, 55 were cases of sexual harassment, abuse, or exploitation (SEAH), compared to 63 in 2019. Twenty-eight (28) staff were dismissed as a result of those SEAH cases in 2020 (40 in 2019).
The other confirmed cases of abuse consisted of: psychological harassment (14 confirmed cases); abuse of power (8 confirmed cases); physical violence (3 confirmed cases); and discrimination (2 confirmed cases).
There were also 68 confirmed cases of inappropriate behaviour, up from 50 in 2019 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standards or affecting team cohesion; and substance use).

We have continued to see small but notable increases in the number of complaints submitted by previously under-represented groups, though there remains a lot of work to be done:

The total number of complaints submitted by locally hired staff increased again in 2020 to 172 (up from 144 in 2019). While this may be a marginal success in improving awareness and trust for colleagues to submit complaints, there is still more to be done considering that locally hired colleagues account for 80 per cent of the MSF work force.
The total number of complaints submitted by patients, caregivers, community members and other external parties showed a very slight increase, to 23 in 2020 (up from 20 in 2019). Considering that MSF undertakes millions of medical consultations each year in all our various projects, along with many other forms of contact with the communities we assist, this is very likely to be significant under-reporting. Existing complaint mechanisms need to be further adapted and improved to better reach patients and communities in individual project locations, especially given the extremely vulnerable position of many of those people whom MSF assists.

Complaints from our offices worldwide

Out of 37 headquarter offices (non-operational entities) which accounted for 5,596 staff (10 per cent of MSF workforce) in 2020, 55 cases were reported either through management lines or office-specific behaviour reporting mechanisms.
After investigation, 38 cases were confirmed as either abuse (20) or inappropriate behaviour (18).
Out of these cases, 20 people were either dismissed or received other sanctions, such as formal warnings, depending on the severity of the facts.

We continue to urge staff, patients or anyone else who comes into contact with MSF to report any incidents of unacceptable behaviour which they come across.

2022 update

In 2022, nearly 68,000 individuals worked for the MSF movement worldwide. During that year, we saw a total of 695 complaints relating to either abuse or inappropriate behaviour made across the MSF movement. Of these, 606 were related to our medical and humanitarian projects, and 89 related to our international headquarter offices. Further details below break down project and headquarters cases separately, as they are not necessarily comparable in terms of legal and reporting processes.

The overall number of complaints received related to our medical and humanitarian projects increased by 24 per cent in 2022, compared to 2021. MSF continues to face a challenge to ensure reporting of abuse and inappropriate behaviour, especially from patients, their carers, and the communities we assist. However, the increase in complaints can be seen as a sign that we continue to make progress in addressing this long-term challenge – and that awareness of and confidence in our reporting mechanisms and channels is continuing to grow.

In 2022, we began also to include complaints about ‘exploitation’[i] and violations of the ‘case management process’[ii] in our reporting. The latter was introduced to protect complainants, while ensuring that reporting mechanisms are not misused. Data was also collected about complaints related to ‘inappropriate communication’[iii]

Complaints received related to our medical and humanitarian projects in 2022:

Around 90 per cent of MSF staff (just under 62,000 individuals in total) in 2022 were working in MSF’s projects. A total of 606 complaints were made concerning the behaviour of staff in these projects, up from 490 in 2021.
Of those complaints, after investigation, 204 were confirmed to be cases of abuse or of inappropriate behaviour (158 in 2021), with some cases continuing to be investigated.
This includes 121 cases which were confirmed as abuse, compared to 102 confirmed cases of abuse in 2021 (this covers different forms of abuse: sexual exploitation, abuse and harassment [SEAH]; abuse of power; psychological harassment; discrimination; exploitation; case management – including retaliation and breach of confidentiality; and physical violence).
A total of 52 staff members were dismissed for all forms of abuse in 2022 (54 dismissals in 2021). Depending on the severity of the case, other sanctions were also issued, such as suspension, demotion, formal written warning, or mandatory training.
Of the 121 confirmed cases of abuse, 60 were cases of SEAH, compared to 67 in 2021. 35 staff were dismissed based on the findings of investigations related to those SEAH cases in 2022 (33 in 2021).
The other confirmed cases of abuse included cases of psychological harassment (22 confirmed cases); abuse of power (17 confirmed cases); physical violence (12 confirmed cases); discrimination (3 confirmed cases); and exploitation (7 confirmed cases).
There were also 83 cases of inappropriate behaviour confirmed or found, up from 56 in 2021 (inappropriate behaviour includes: mismanagement of people; inappropriate relationships; inappropriate behaviour not in line with societal standards or affecting team cohesion; inappropriate communication; and substance [mis]use).

For the first time since we started reporting these figures, the total number of complaints submitted by locally hired staff in our programmes decreased in 2022 to 232 (down from 262 in 2021). More still needs to be done to encourage locally hired staff in our programmes to come forward with complaints, as they make up nearly 80 per cent of the global workforce but only represent just over one-third of complainants.

The total number of complaints submitted by patients and their carers increased slightly in 2022, to 67 (up from 53 in 2021). In the context of the millions of patients MSF sees each year, it is concerning that the number of complaints from patients and their carers continues to remain low. This is a clear indicator that, although efforts to inform patients and carers of expected staff behaviour standards and complaint mechanisms are ongoing, more needs to be done to advise patients of their rights and ensure access to reporting mechanisms to hold MSF accountable for any abuse or inappropriate behaviour.

The number of complaints submitted by “other” external parties – a category which includes suppliers, members of the media, members of other organisations, community members, partners, ex-MSF staff, non-MSF contracted staff, MSF association members, and anonymous complainants –increased to 107 (from 37 in 2021).

There remains a relatively low number of complaints made relating to discrimination and racism, despite ongoing movement-wide efforts to address these issues. A total of 40 complaints relating to discrimination were received in 2022, up slightly on the total of 32 in 2021. Existing efforts on highlighting diversity and inclusion in behaviour issues need to be scaled up, as does encouraging people to speak up.

Complaints from our offices worldwide

MSF continues to compile complaints from our offices around the world, in addition to the data gathered from our medical projects. Ten per cent of the total MSF workforce is based in these international offices.

While efforts have been made to standardise reporting, this data relates to many different legal and human resource processes, and so may not yet be fully harmonised.

Out of 38 headquarter offices providing data, 89 complaints were received in 2022 (up from 49 in 2021, across 38 offices).

Of these, 44 cases were confirmed, with 38 cases related to abuse and 30 to inappropriate behaviour.[1] This compares to 19 confirmed cases of abuse and 11 of inappropriate behaviour in 2021.

Overall, 17 sanctions or dismissals were given in 2021, compared to 13 in 2021.

***

We continue to urge staff, patients, or anyone else who comes into contact with MSF, to report any incidents of abuse or inappropriate behaviour which they come across.

[1] Note: one “case” can be qualified as several offences, so totals may not match.

[i] Exploitation (separate from sexual exploitation) relates to someone using their authority, influence, or control over resources to pressure, coerce or manipulate a person to do something in exchange for resources or offer of resources.

[ii] Case management process relates to abuse around retaliation, interference in a case, false reporting, and breach of confidentiality.

[iii] Inappropriate communication relates to any spoken, written, or non-verbal language that is not respectful of others or their environment, even if it does not constitute abuse, which includes using an aggressive, annoying, or insulting tone.

2023 Update

Published 16 July 2024

In July 2020, the international leadership of Médecins Sans Frontières (MSF) made a public commitment to tackle discrimination and racism within our organisation. The Core Executive Committee (Core ExCom) pledged to “lead the way for the radical action sought after and demanded by our associations.” This commitment came amid powerful global movements for racial equity and health equity, spurred in part by the impacts of the COVID-19 pandemic. It also followed years of advocacy by MSF staff calling for change.

In 2020, the Core ExCom (see glossary below) defined an action plan, identifying seven priority or key areas as requiring urgent and concrete action:

1: Management of abuse and inappropriate behaviour

2: Staff reward, including remuneration and benefits

3: Exposure to risk – safety and security

4: People recruitment and development

5: Communications and fundraising

6: Standards of care for the patients and communities with whom we work

7: Executive governance and representation

In early 2022, we provided an update on progress for the previous 18 months, up until December 2021. Nearly four years on from the Core ExCom’s initial commitment, and two years since the last update, we are outlining our progress on these seven areas over 2022 and 2023.

We are publicly publishing our progress, as we want staff, patients, communities, donors, stakeholders, and the public at large to see where we stand on each of these areas, including areas where we are struggling to move forward. Doing so is the best way to be transparent and demonstrate accountability for our actions. We took stock of what we managed to achieve in the last two years – and where we still have work to do – at the end of 2023.

While we worked on all of the above seven areas, the Core ExCom prioritised tackling issues of abuse and inappropriate behaviour, and addressing inequities in our staff rewards and remuneration system.

“Our staff, association members, partners, donors and the communities we serve are expecting results on the areas that we have committed to improve. While we have made significant progress in some areas since the launch of the Action Plan, in others, we recognise that we still have more to do. This is why we commit to creating an updated Action Plan with clear milestones to take us to the finish of our current strategic period at the end of 2025. Today, we hope that this update provides some idea of the progress that we’ve made, and that our stakeholders continue to hold us accountable on achieving this important work.”

Dr Christos Christou, MSF International President

This is not an exhaustive list of all initiatives to tackle discrimination and racism in MSF, but a summary of some of the main movement-wide progress made since the launch of the Action Plan, based on priorities agreed by MSF’s Executive Committee (ExCom). There are countless initiatives being carried out in our projects and Operational Directorate (OD) headquarters that are not covered in this update. For transparency purposes, we have retained the update we provided in February 2022, for the progress made during 2020 and 2021, which can be found at the bottom of this page/here.

To provide clarity and aid understanding of MSF’s decision-making and leadership platforms, we have included a short glossary of terms within MSF referred to in this document.[I]

Management of abuse and inappropriate behaviour

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.

Staff reward, including remuneration and benefits

“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, MSF 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.

Exposure to risk – safety and security

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 lies 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.

People recruitment and development

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 (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.

Communications and fundraising

“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, MSF 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.

Standards of care for the patients and communities with whom we work

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.

Executive governance and representation

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.

Conclusion: Progress is being made – but there’s still a lot more to do

[i] Glossary of MSF decision-making platforms

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. Full details here.

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.