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, 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.

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, 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.

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.