Filtres et coupe-circuits

Chapter 6. Filters and Circuit Breakers

Introduction

This chapter examines the power concentrated in international staff in management positions, and in particular, coordinator positions, which are seen by many locally recruited staff as ‘filters’ for the opportunities, security, and participation of ‘local’ employees at project sites. First, the chapter describes these positions and their capacity to filter information, translate policies in practice, block actions, elevate individuals, or to act as circuit breakers pertaining to opportunities, career progression, security, and participation. The second section examines some of the implications, drawing on the experiences of different staff members. It examines the potential of coordination positions to shape opportunities for locally recruited staff, such as access to training or postings; how opportunities for participation can be mediated or enabled by those in coordination positions; how they influence decisions around security; and how they have direct and indirect implications for the health of various staff members.

6.1 Who are the filters?

Filters of coordination

MSF country management structures are hierarchical. Decision-making power is centralised in coordinator positions, which are the contact points that link projects ‘in the field’ with senior programme managers at ‘headquarters.’ At country level, a Head of Mission and Deputy Head of Mission oversee operations, manage security, and are responsible for the in-country team as a whole. The country teams are divided into different departments, such as Medical, Logistics, Human Resources, Finance, Humanitarian Affairs and Communications. Each department is led by a coordinator: Logistics Coordinator (LogCo), Human Resources Coordinator, and so on. Medical Coordinators and their deputies are responsible for medical programming in country as well as for staff health. At project level, this structure is mirrored. Project Coordinators and their deputies lead daily operations and security management of specific project sites, and are managed by the Head of Mission. Each department is led by a manager or ‘team leader’ at a project level.

Coordination positions are deputised, and often paired with a locally hired ‘assistant’. Ultimately, coordinators supervise a department with a majority of locally hired staff. In most cases, these senior leadership positions are reserved for internationally mobile staff on short term ‘missions’ or ‘assignments.’ As the review of diversity and inclusion in OCA from March 2017 explains, these positions are viewed as “‘feeder’ positions for operational decision-making positions in Headquarters” (Adatia, 2017, p. 4). The ideal length of a ‘mission’ is 12 months. However, the length of these postings ranges from three months in ‘emergencies’, to up to three years in some settings.

What is filtering?

Coordinators have the power to filter information and determine action and may act as either blockers or circuit breakers – to translate, rework and apply existing rules and structures in a way that they see fit. This has important operational functions in an organisation that specialises in emergency medical programming. The organisation prioritises flexibility and speed; the ability to respond to urgent need quickly (see Chapter 3). In this context, individuals need to be able to make decisions quickly, rather than relying on lengthy bureaucratic processes – processes which may not, in any case, be well suited to the specific situations they encounter.

There are long running tensions in MSF about the degree to which operational decisions should be made at headquarters, or in project locations by coordination teams. While different coordination roles have different spheres in which they exercise their decision-making, the Head of Mission position was frequently raised to illustrate the level of power as well as the varied forms authority can take:

“There’s the power that you can have as a Head of a Mission, you can inspire your teams and they give you the power to accomplish what you need to do. Or you can leverage the power that you have in the name of your position to do what you need to get done. I think depending on who you are and depending on what the situation is, you use both of those, well, to varying degrees, to accomplish what you need to do. Depending also on what context you’re in and what, yes, what the urgency is, also depends on how you use that power.”

Heads of Mission and Project Coordinators, another suggested, were like “mini-General Directors” at different scales.

Heads of Mission are managed by ‘Desks’ – Operations Managers in Amsterdam who oversee a portfolio of different countries. Coordinators are the leadership of the organisation in the country. The Head of Mission is legally responsible, and decisions about what takes place operationally in a particular country are the outcome of discussions between the Coordination and the project, and the Coordination and the Desk. The annual strategic planning for programmes is proposed by projects before being discussed with coordination teams, and ultimately decided at headquarters. However, employees in Amsterdam highlighted that day-to-day, coordination teams have a significant degree of autonomy. Despite the oft-repeated narrative about power being centralised at ‘HQ’, the daily running of operations is managed by country coordination. They are “strongly influenced and constrained by what is discussed within the movement, but there are nonetheless a lot of things that can be managed at this level.” An experienced employee said that rather than strictly following pre-planned policies, “MSF is based on people, so people have a lot of power when you are Head of Mission, you can really be a nightmare for the project, or be a changemaker.” An experienced Head of Mission agreed:

“As the Head of Mission, you have an enormous power. What we do, how we do it […] you have an enormous freedom to set it up the way you want to do it. From the desk level, they will influence you but if you are a strong Head of Mission, and if you have the trust from headquarters, you are pretty much free to organise it the way you want to organise it […] the way the teams are working […] how you work with your national staff, how much influence you give them, you really have that power as a Head of Mission.”

When describing how power operates in MSF, locally recruited staff described coordinators as filters between headquarters and ‘the field’. While coordinator positions inherit position-specific email addresses and are a direct line of contact with headquarters, not all locally recruited staff have MSF email addresses. Usually, email addresses extend to the supervisor level in projects, along with all office positions in coordination. As a result, many locally recruited staff at a project level are not in contact with OCA beyond the country in which they work. As a result, their managers can mediate the projects and their relationship with Amsterdam. Language also plays a crucial role: as outlined in Chapter 4, management positions need to be able to communicate in English. In many countries where OCA works therefore, many staff were excluded from these channels of communication, which were instead filtered through coordinators. In effect, these coordinators could become communication conduits.

6.2 Filtering in practice

This section describes some of the implications for different staff members within the organisation. Locally recruited staff described four main mechanisms through which coordinators and international staff in management positions acted as filters and circuit breakers: mediating opportunities and career progression; limiting or enabling opportunities for participation and communication; translating policies on safety and security; and health evacuations for staff members in practice.

Opportunities

Locally recruited employees argued that coordinators can filter which opportunities are forwarded to whom, and who is recommended for new positions in country, or for trainings, detachments, and expatriation abroad. Therefore, international staff in management positions can shape the career prospects of the team they manage: “It’s a great thing if you have a supervisor that appreciates you. And it’s kind of sad for people who have no one to push them forward.” Interviewees described the importance of personal relationships:

“That’s why I said that the inequalities are created by the head office, although they send out documents and procedures to follow, even if it is well thought out, they are not respected at the project coordination level and that’s where it gets tricky.”

In DRC, for example, there was frustration at the perceived role played by recommendations from internationally mobile staff in shaping career trajectories: “In short, national staff who are not friends of expats or senior staff will have difficulty if they are trying to change positions, even if they have skills.” Another locally recruited employee added: “When someone is in a position of power, everybody wants to get close to them […] they are influenced by their network in the decision-making process, and that can affect other people.” Local staff were concerned about how key decisions were taken by international staff in management positions who may be inexperienced or easily influenced:

“If you are friends with a supervisor who doesn’t really understand his job, they may only give incentives to some people and leave out the others, be it training, work, or benefits. This is problematic because it is the manager who is supposed to evaluate the abilities of the employee and determine if they deserve their position or not, in an impartial way and not according to the affinities and the friendships between colleagues.”

Rather than promoting staff, human resources open internal recruitment processes within country programmes, with the aim of mitigating against favouritism. Nonetheless, locally recruited employees had the impression that these positions were opened with somebody already in mind, based on who the supervisor thought was fit for the role, “the decision was already made,” one Syrian employee explained. Another concluded: “some people don’t apply for internal recruitments, because they know already who will be in the position.”

Learning and Development posts have recently been developed in OCA, with some positions established in different ‘missions’ to help facilitate training and career progression. Online training modules have been developed. For instance, ‘Tembo’ provides learning development opportunities for MSF staff anywhere with an internet connection, with the objective of enabling “everyone to be better prepared to contribute to MSF operations.” Locally recruited employees described an improvement in access now that trainings were online, “Before, if your supervisor, who was supposed to let you know about new training courses, wanted to do it himself, he wouldn’t let you know. But now, if it’s online, everybody can do it.” Despite this, locally recruited staff described how they still relied on coordinators forwarding potential opportunities for in-person trainings, or recommending them. “It depends on the supervisor! If they like someone, then you will see that person is always going to things.”

As a result, some locally hired teams had the impression that the same colleagues were being selected to attend trainings, even if these individuals were not in the best position to share these new skills with the broader team. In one focus group, an employee described:

“Covid was very new. So, we asked for some training. At last, later, the training was given […] and we [hoped, that from] the Covid, or ER for emergency room, one of the staff should be taken for training. So that we can manage the Covid […] but later we find out, somebody, our boss just went and picked from other department [….] not Covid, not ER, they just went to other department: ‘Come and do the—, go and attend the training’… So now that guy might not manage to come and work in ER or in Covid. He just keeps the skills there with him […] So the skills that he gained from that training, it stayed with him, died with him, without practice and where can we go from there?”

Career progression

To occupy senior decision-making roles, most locally recruited staff must leave their country. There are two processes for this. The first is a ‘detachment’: being employed for a short period of time abroad in an international posting. This is a means to increase mobility and opportunity for locally recruited staff in MSF, but also a means for OCA to fill ‘gaps’ in personnel. The second is ‘expatriation’: applying to become an internationally mobile staff member. This requires a level of English, being added to a ‘pool’ and being matched with a ‘mission.’ Although there are formal application processes, again, locally recruited staff stressed the role of international supervisors in forwarding opportunities and making recommendations. In terms of who is selected, employees felt “there is no transparency with how these decisions are made, we are not informed at our level. […] We remain lost in the clouds.”

As a result, interviewees argued that the process should be further formalised and oriented away from recommendations by supervisors:

“If you are a national staff, you must get the recommendation from your top managers […] but how can my coordination know my core status or my capability? […] Instead of centralising the power of recommendation, if you are national staff you should be able to apply for the position, and then indirectly they can check your HR, look at your record, check your evaluation, your capabilities […] maybe they can call and do an interview with you […] If it’s something you’ve been doing for 10 years, you must have some knowledge. How can the person know? You need to give them a test. Test them. Give him an assignment.”

In this way, locally recruited staff were critical of the fact that international staff in management positions were often only there for short periods and remained removed from local staff’s everyday work. Yet, it was these managers who could shape career trajectories.

Internationally mobile employees recognised that recommendations played an important role:

“It is sad to see, but it is related to who you are friends with. If you’re a national staff and you have a good relationship with a LogCo who is an expat, that LogCo can easily push to get you detachment. If you are a little bit shy or you’re not very open to speaking, nobody will give you the opportunity.”

Employees at Amsterdam contact HR Coordinators to ask if they have any recommendations for locally recruited staff who might be suitable for detachments or expatriation. This means that “it depends, within the mission, whether a person is on their radar or not, if he or she is pushed forward.” In effect, internationally mobile staff had access to headquarters that locally recruited staff lacked, also allowing them to break through circuits that appear closed. A Congolese employee gave an example of applying for two international training courses (for which they had official approval) and being told that both were full. They mentioned this to an internationally mobile colleague, who said: “No, I know how things work in Amsterdam, give me those applications, I will come back to you.” Two days later, they received a positive answer from Amsterdam that there was availability.

Once in the ‘pool’ of potential internationally mobile employees, people who are well known may find international postings more easily, highlighting the currency of friends in high places. Being known or connected “makes it easier to get the position, as long as you have the skills and experience that we need.” While some emphasised the perceived functionality of this approach in an organisation that often works in unstable environments, others highlighted its potential to reproduce existing patterns of dominance or marginalisation. One internationally mobile employee commented:

“As an example, a guy admitted in the pool from Uzbekistan waited a year and a half, national staff, before having an international position assigned. I can tell you, I’m sure there were a lot of other vacancies […] because he’s national staff somewhere, maybe he has less means than if he was a Dutch person who lives here and knows people in the office and went and pushed for his own matters.”

An employee who had moved from an internationally mobile career to a headquarters position described how sometimes the career trajectory of locally recruited staff could be influenced by:

“The right conversation, the right night with the right person, who then starts the process. And, that starting is random […] Unfortunately, the fair part of power, of that type of power in MSF is here, here and here is completely unfair, and completely random. Random in this situation, not random in this one. So, the 20 years European person will still have a voice in panels, will still be invited in the ‘MSF We Want To Be’ et cetera. The 20 or even 30 years Congolese will not. And so, there is an aspect here of, I wouldn’t say equality, but fair opportunities that is limited.”

This comment highlights the links that some draw between individual career paths and patterns in who is able to participate in the organisation, as well as the self-image that the organisation puts forward to its personnel.

Good relationships with international managers at different levels, then, was seen as an important source of power among locally recruited staff. This created tensions within MSF teams. A former locally recruited employee described how pursuing an opportunity within MSF:

“Depends on your connections and how many people you know at different levels [of the organisation] because certain individuals might be more in touch with people in power, and there is not a system, there is a lot of reliance on these individuals… they [headquarters] trust them and there is a lot of work done only through this channel.”

At a project level, they described the realisation among locally recruited staff that being close to an internationally mobile supervisor was important: “The moment the mission is over [for that supervisor] someone else comes and they start getting connected with someone else. This results in conflicts internally…it can create a lot of clashes among the team members.”

Coordinator positions also had the power to block – not forwarding opportunities to locally recruited staff at all. For instance, regarding detachment opportunities, one employee claimed: “It goes like this: HR asks your supervisor and if they agree to let you go then they inform you. But otherwise, you’ll never know.” One employee working in Learning and Development at headquarters said that “in the past, it [international training] was only there for expats, and in certain cases, we had certain national staff also attending trainings, but it was looked at rather as a favour.” The expectation is now that OCA should be sending more locally recruited staff on international training, but this relied on internationally mobile staff to help facilitate. The employee explained:

“The difference of resources [attributed] is huge for development of a national staff versus an international staff, but also, that expat who’s supposed to support their staff, they don’t […] I can easily say 80% of the time, they don’t have the expertise to give the adequate support. 80% of the time, they don’t even know for themselves how to develop their career. […] It’s always hierarchical, and thinking of that hierarchy, […] it’s 80-90%, again, people not from that country and 70% of the time from Europe, who make a decision about someone’s career.”

The employee described the reaction from Amsterdam when they put forward locally recruited staff for training opportunities abroad: “We’d rather recommend to send trainers to your mission and we do training there.” While there is a rationale for this in learning on the job, the contrast with the practice of travel for training abroad – and the perceived access of internationally mobile staff to such trainings – sent the message that “they’re still biased, these people in HQ, the Europeans, they still want to keep that power. They don’t want us to learn.”

Locally recruited interviewees had the impression that internationally mobile staff were too often prioritised for some opportunities. In DRC, a locally recruited member of staff said: “For example, I request this training for at least two years, but the team leader will give preference to the expatriate who recently arrived over me because there is only one place.” This was further complicated by the fact that the majority of training in OCA was in English, meaning that locally recruited staff were unable to access it, or believed that they were immediately filtered out by their Anglophone managers.

Communication and Participation

Coordinators can become the key channel of communication between Amsterdam headquarters and staff in project sites. One international employee said: “There are set communication lines and it is hierarchical. There are also people that don’t like it if you don’t follow those communication lines. So, I just think there is a lot of opportunity for information to be missed.” Indeed, locally recruited staff described a “communication hierarchy,” whereby many staff in their day-to-day work in programmes have no direct communication with headquarters. Information was filtered through their senior international colleagues. As a result, among locally recruited staff, there appeared to be some confusion about how strategic decisions were made. One local employee explained:

“I, for example, can’t write to Amsterdam and ask why things are the way they are because I do not have the authority to write to Amsterdam, communication-wise. But is it a sin if I write to the headquarters to tell them about a problem and ask if they can clarify things? It’s not possible, because, on the communication hierarchy level, I am not allowed to do this. I should be reaching out to my supervisor or my Head of Mission, but that also depends on whether I am on good terms with them. If that’s the case, I can take advantage of that.”

In a focus group in DRC, an employee summarised the general feeling when they joked: “If you try and get contact with Amsterdam, you are creating your own tomb.”

The dominance of those in coordination positions is seen in the emphasis on English (see Chapter 4). Staff in the country programmes have to find ways of navigating the presence of people who do not speak any of the national or vernacular languages. One international employee described it as “troubling” that in OCA programmes:

“You would have a large team of expats that didn’t speak the local language, and I’ve been in missions where you have a Project Coordinator that doesn’t speak French and so we’re holding meetings in English with an entire national staff that doesn’t speak English, for the benefit of the Project Coordinator.”

A senior Congolese staff member described the added work of translation that falls on multilingual locally recruited personnel who serve as points of exchange between staff who work in different languages. A Syrian employee initially downplayed language requirements, saying (via an interpreter) that “there are some positions that really require you to speak English, and there are many other positions that don’t require you to speak any English, just Arabic.” They went on to describe the level of proficiency required:

“You don’t have to be very knowledgeable about English language, you should only be able to communicate on a daily basis, just to give them [internationally mobile staff] an idea about the concerns at work, and you speak that in English […] just give them an idea about what happens in the region.”

Some country programmes are seeking to develop policies for English language development for locally recruited staff. However, one interviewee challenged the motivation behind such programmes:

“It looks like the goal here in MSF Holland is they want all staff speaking English here. […] We had a course here in English, just pushing people to speak English, because tomorrow, they are going to ask you to write a report in English, because Amsterdam they don’t know, they didn’t speak in French.”

In all of these examples, it appears locally recruited staff play a central role in making a multi-lingual environment work.

Despite this translational labour, interviewees highlighted the limited participation of locally recruited staff in operational discussions. An international employee explained:

“I can say that in technical aspects almost no one from the local team gets involved in the high-level planning. It’s just 10 expats sitting in a room deciding where the project needed to go for the next year which is really sad actually because you’re basically ignoring all past history and you’re not giving the responsibility to people to be involved, and they want to be involved.”

Every year, the strategic priorities for the next year of a project are discussed in country, and then discussed with Amsterdam, in order to make strategic choices about programme design. However, for locally recruited staff, it often remains unclear why certain decisions are made. Sometimes, the final decisions do not seem to reflect the opinions and ideas that the teams in country had shared with coordination: “It’s up to the personal relationship that you have with the supervisor, but if you don’t have a good relationship perhaps all your good ideas will be rejected.” Another local employee added:

“At the very least, a meeting should be held to inform employees and explain the strategic choices. But this has not been done. So, people wonder why they were included in a long strategic thinking process, at the end of which nothing suggested was adopted. This is not right…. I don’t know if these people decide on their own not to justify themselves to the staff or if it comes from their hierarchy.”

In effect, there was a widespread lack of trust among locally recruited teams in OCA’s formalised decision-making processes. Indeed, national teams said it remained unclear who had made the final decision: “they [coordination] say Amsterdam, but who is Amsterdam? Amsterdam is a man or a woman?” Many concluded that coordinators in country make key decisions: “perhaps Amsterdam is not even informed about that decision.” As foreign employees rotated in and out of different programme sites, staff experienced a process of what one interviewee called “repetitive reinvention,” led by the same individuals who have the power to filter the information they receive and to shape the ideas communicated back to Amsterdam.

Locally recruited teams working in the medical department questioned how decisions were made in the organisation, and in particular, the role of “the data.” One interviewee summarised that a “semblance of legitimacy [is] provided to the decision making because it was based on data.” Locally recruited medical employees described collecting vast quantities of ‘data’ in project sites. This data was then passed ‘upwards’ and the ‘users of data’ were at coordination level or headquarters. A hospital coordinator support said:

“When it comes to the decision making, for us in the field, we only give the information to coordination. For example, if we identify alarming things, we have to give the reports to coordination, and coordination will have to either go with other actors or maybe report it as well to the headquarters. And the headquarters, now, will have to think what can be done, what could be the role of MSF and should we give it to other actors?”

There are “piles and piles of data,” an evaluator indicated. However, for employees at a project level, it was less clear how this data was subsequently used, or how it influenced decisions that were then made in the organisation:

“A lot of energy at the project is going into this medical monthly reporting, and there are questions about whether or not the purpose and the use is clear. Also, whether or not project level staff and co-ordination level staff are benefiting from the process.”

In short, information for HQ was described as paramount – the way that this data was then used to make decisions remained unclear. One focus group participant said: “Everything we have said about healthcare, they have to wait for decisions from the headquarters.” Others concluded that “‘Amsterdam has decided’ is like the word of a Catholic priest”; it cannot be debated.

Coordination roles were also described as communication conduits when it came to associative life and processes. Although, in principle, motions passed in associative forums should have implications for country programmes, in practice, as a rule, interviewees argued that “we don’t have proper systems [to ensure that] there is space for people to raise issues and to see their recommendations put in place.” Congolese employees, like locally recruited staff we spoke to elsewhere, valued the association as a space to challenge and shape the organisation. Yet as one employee explained, filtering and circuit-breaking roles apply to associative life too:

“The association is the only opportunity one gets to point out things and suggest alternative ways. But sadly, on-site, the associative has to be supported by the Heads of Mission or the Project Coordinators. Sometimes, these people are not associative members. They don’t care about these associative things, and they sometimes do not even know how it works. And sometimes they do not agree with what you plan or suggest, and they tend to defend themselves instead of accepting the recommendations and seeing how to improve things. But these challenges don’t stop us from going on with the debates, or from sharing our suggestions and recommendations to make things better.”

A member of the association support team at headquarters level agreed that the buy-in of staff in coordination roles is essential because “if they are not aware of it or if they don’t accept it, it’s very hard for the ALFies [who promote associative life] in the field to get some space.” Numerous interviewees highlighted factors such as staff in senior roles who are not invested in the field aspect of associative life, resistance to input, day-to-day operational priorities taking over, and turnover of individuals resulting in lack of knowledge so that “the chain is completely broken.” According to experiences in DRC, there is also a lack of financial autonomy: “The executive can just not allocate a budget to the association, or decide to use that budget for other purposes that the Head of Mission or PC chooses without even notifying the associative members.”

The attitude of individuals plays such a large role because, although there are mechanisms to convey motions or reports from the Field Associative Debates to higher levels of the associative, there is no system for follow-up or accountability. A former Head of Mission explained:

“Basically, what the [country staff] have to say is not escalated, and if an answer has to be communicated back, that too takes a lot of time, as it needs to go through the Operational Centre, the General Director, the Operational Director, the Desk Manager, and the Head of Mission. It is a very long process, so the probability of a message or the voice of the [locally recruited] employees getting through is very low.”

The result is that “the associative is controlled by the executive, when it is supposed to be watching this executive closely.”

Evacuation and security

Locally recruited staff were critical of the fact that they were often excluded from decision making around security protocols and procedures that directly impacted their own safety. Indeed, many interviewees highlighted that the security plans for different projects were often formulated without input from locally recruited staff.

There was much debate about MSF’s evacuation policies. The general principle in MSF was described by interviewees as: “the role of MSF is to bring you back to your exposure level before MSF […] so we don’t evacuate people from their own countries.” While some locally recruited employees suggested that MSF may not have the capacity to evacuate hundreds of staff (indeed, in some contexts, such as Syria, this was impossible), others were generally critical of evacuation procedures. At project sites in eastern DRC, for example, employees said: “They tell us: ‘expatriates are not at home, you are at home.’ So, people who are at home must flee, to survive. But ultimately, we all have the same risk of losing our lives.” Locally recruited staff said that when they asked about evacuation policies: “We are told that you ask for too much.”

In North-East Syria, locally recruited staff are at particular risk precisely because of their work with MSF, which is described as a terrorist organisation by the Syrian government. OCA operates in the region without the permission of the central government; locally recruited staff were exposed to risk precisely because of their employment with MSF. While recognising that it is extremely difficult for Syrian nationals to leave Syria (passports are issued by the central government in Damascus, which is in opposition to the Kurdish-dominated Syrian Democratic Council which governs the North-East of the country), Syrian staff were critical about the way that MSF provided protection in vastly different ways for employees on different contract types. This raises particularly salient questions about MSF’s obligations or ‘duty of care’ (see box 5).

BOX 5: DUTY OF CARE IN SYRIA

Syrian staff described facing multiple personal security risks. One Syrian interviewee said: “The Syrian regime considers them [MSF] a terrorist group. But at the same time, the result of lack of job opportunities […] means that you need to work. Money doesn’t fall from the sky.” For many, their impression was that their ability to seek help from MSF depended on the personality and views of the particular foreign coordinator in place:

“OCA cares more about the work, than people [employees]… I live in an area that’s under the Syrian government. So, for sure, I have loads of security issues, but when they come and they bring this on the table of the PC or someone, and they say that: ‘It’s work. We don’t care, find your solution.’ […] You know, the problem with OCA, there’s no strategy in place. You depend on the people. This PC, she’s really caring a lot, and she even called me to speak and find the solution for my situation, while the previous PC did not.”

Locally recruited staff gave their informed consent to work for MSF, and the organisation developed a ‘duty of care’ policy. This policy provided Syrian employees with a ‘package’, which included a financial payment (the equivalent of three months’ salary for contracted staff and two months’ for incentivised staff), or compensation in case of a major event; the number of a psychologist; support for people to seek jobs with another organisation if they felt that offered additional protection; and support with documentation in case they wanted to apply for asylum. At the same time MSF’s official position remains that they cannot help employees claim asylum in other countries. The idea behind the package was to provide people with the financial means to improve their situation and take care of themselves and their families. However, according to one Syrian employee, the duty of care stipend falls short of meeting the costs of leaving Syria:

“So, the monthly stipend is not really enough for the national employees to flee, in case anything urgent happened. Also, the stipend is not really enough and if there is any possibility that you could increase this stipend—, because even if the national staff want to run away or to be, actually, smuggled out of Syria, they will need more money because smuggling really requires a lot of money.” 127

BOX 5: (continued)

In practice then, the package falls short of its implicit goal. Another central part of the Duty of Care policy was the continued attempts on the part of OCA to gain registration with the Government of Syria, which have thus far remained unsuccessful.

In 2019, Turkey invaded North-East Syria. OCA evacuated internationally mobile staff, and all programmes were suspended. All staff were paid their salaries as well as the additional payment for ‘duty of care.’ After these payments and suspensions had taken place, it became clear that there might be an opportunity to work in the area again. As a result, a small team of Syrian employees restarted activities, while international staff led operations through remote programming for several months before returning to Syria.

For Syrian employees, this event highlighted the limits of the duty of care package. As one employee summarised: “In 2019, we recognised that MSF left the national staff behind them, and the mitigation process, the thing that protects the international staff, it’s much, much stronger than to protect national staff.” Another staff member reflected: “I know the duty of care needs to be re-discussed, not just amount of money to provide to staff, to protect them. There should be another way to protect national staff.” In a focus group, other Syrian staff agreed:

“We are assuming that the Syrian regime is not coming here, but once they are here […] all the staff who had worked with MSF or MSF specifically, they have more or less a problem with them [the Syrian regime]. They would have had many issues, many problems with the regime. The package, is not, not only the package that the staff need, they need protection. We ask a lot, we mention in a lot of meetings that at least, to have this approval with Damascus.”

Another employee said:

“If MSF evacuate or the Syrian government come back to control these areas, so we’re all going to be at a big risk actually. I don’t know how MSF can solve this issue, but I think that they need to take it seriously.”

In other settings, interviewees were also critical of the way that decisions about evacuation were made in OCA. Their impression was that certain evacuation decisions depended on the international staff in coordinator positions, who could determine how security plans were implemented in practice. As one operational employee in Amsterdam put it, “because it’s so hierarchical, the Head of Mission is king or queen. […] Your life is literally in their hands.” There appear to have been instances when international coordinators made the decision to evacuate everyone, even local staff, where they could. A Congolese employee gave an example:

“But that also depends on the decision-making power. I always give the same example of [this] project. At some point, the evacuation had to happen. I remember the Head of Mission at that time decided to evacuate everyone, even the locals and their families that were part of MSF. So that was also a situation that made me think that within MSF, you have that space to contradict certain decisions and to decide otherwise and take responsibility. But if we have to follow all the MSF rules, it can be pretty discriminatory.”

Coordinators could therefore act as circuit breakers – getting past restrictive policies on paper to go beyond these commitments on the ground. Nonetheless, this depended on the decision-making of one individual, in the context of high turnover in the organisation.

Similarly, the way that duty of care was applied to different cases was a process of interpretation. ‘Duty of care’ and ‘solidarity’ are two contested concepts within the MSF movement, that are applied differently in different contexts. In general, as one former Head of Mission explained, duty of care refers to a “contractual relationship and exposure caused by MSF,” while solidarity is “more about what can be done beyond the employer’s responsibility.” However:

“The duty of care is sometimes used as an excuse not to help people as if there is no duty, then we should just not care […] people were twisting the concept and turning it into a tool to avoid having to do things. We were both the judge and the defendant at the same time.”

Instead, this employee explained, the instances where locally recruited staff were evacuated or taken out of high-risk contexts were the result of “individual informal initiatives” led by different international staff. Similarly, an international employee in Amsterdam described how duty of care “is not a science,” but an act of interpretation: “the moment we have a criteria for it, then it should be called something else.” Instead: 129

“It’s made out of principle, it is those in charge at the moment that make the decision and the rest should just respect that and defend it […] While I want our Head of Mission to be able to explain all of their decisions, duty of care decisions cannot be explained fully, (a) because they’re confidential, and so others should not know about it or (b) because they were decisions that were made out of principles, not out of policies.”

In this way, coordinators could facilitate the evacuation of particular staff members. However, as an interviewee added, this meant that personal relationships shaped how duty of care is applied in different cases:

“Personal relationship, of course, like in everything, plays a role. It’s not only personal relationship with the person concerned but personal relationship with those decision-makers, among the decision-makers […] we see personal relationships play out way more than in any other organisation that I’ve worked for, regardless of the job description, how strict it can be, we have a flexibility that I have not seen in any other organisation, for the good and the bad at times.”

Health evacuations and referrals

Locally recruited employees highlighted the different health referral processes for locally recruited and internationally mobile staff as central to how inequality manifests inside the organisation. The issue of health referral was described as a major ethical dilemma in MSF: not only in relation to staff health, but also patient referral. In effect, decisions about whether to refer patients and staff bring into stark light the profound inequalities in health provision based on geographical location, and illustrates how MSF’s everyday work may reproduce, rather than actively combat, such structural inequalities and politics of life (Fassin, 2007).

Drawing a distinction by staffing contract in the provision of healthcare is key to how power is inscribed in the organisation. So great is the difference between the two systems the organisation uses that one medical employee insisted: “we cannot compare the management of local and international staff healthcare.” Locally recruited staff discussed the intricacies of specific referral policies in different settings, and the ways that they reproduced forms of inequality. These dynamics must be approached empirically, although they reflect widespread and perpetual tensions between different considerations that shape MSF’s work and the care its employees receive. The discussion here is based on issues raised by interviewees in DRC.

Two key features of health provision for staff are relevant to understanding the powers of filtering and circuit-breaking roles, as well as inequalities more broadly. First, that provision of care is structured by contract type. According to the policy, internationally recruited staff can be transferred within DRC, but also outside the country, for emergency medical care. The cost of medical care, travel, and accommodation is covered by MSF. Meanwhile, Congolese staff are treated locally. If the required services do not exist locally, then staff are referred within the country and MSF will pay for their treatment. In the case of an emergency, MSF covers domestic travel and accommodation as well as the medical treatment. Otherwise, Congolese employees must cover the costs of their own transportation and accommodation. MSF does not pay to transport Congolese staff outside DRC or for international care.

An experienced Congolese employee described the problems with this system. Congolese employees and their families struggled to pay the costs of travel from rural project locations to Goma or Bukavu, as well as accommodation. In Walikale, for instance, travel to and from the project requires flying, which is expensive and does not always follow a frequent or reliable schedule (flights are operated by the UN Humanitarian Air Service). As a result, local staff who require a referral need to find the money to pay for the ticket as well as accommodation until a return flight is possible, even if the treatment itself takes less time. Because seeking medical care requires taking time off work, employees described waiting for approved leave to get treatment. Travel to Kinshasa was more expensive still; one employee noted they had never seen Congolese staff referred to Kinshasa for treatment. Kigali, the capital of Rwanda, offers quality treatment and is closer to eastern DRC, with affordable travel options, yet because it requires crossing a border is excluded from care options for locally recruited staff. Congolese staff criticised the fact that MSF does not pay for healthcare for locally recruited staff beyond state borders: “That would allow us to benefit from high quality care for the staff. When it comes to international staff, the question is not even asked.”

Because this policy entails different allocation of resources to staff on different contract types, it has prompted questions among locally recruited staff about the value placed on different lives. Interviewees were critical of the fact that financial costs and logistical challenges are no obstacle to internationally mobile employees receiving care outside the country, yet, according to them, locally recruited personnel are denied this option even when it would mean reduced financial and time costs – i.e., the non-medical costs which, unless it is an emergency, they pay for themselves. This led Congolese employees to conclude that: “they [MSF] will spend as little as possible on national staff.” Another employee added: “What’s the point of working in a humanitarian organisation that can’t even take care of its own team? Without the staff, you will never be able to reach or help the population.”

Second, implementation of the policy relies on the internal hierarchy of decision making. Decisions about medical evacuations and referrals are taken by the Medical Coordinator, in liaison with the Medical Team Leader in a project. If it is not considered an emergency, then the Medical Team Leader writes to the medical department at coordination to organise treatment outside the project location. However, if a locally recruited employee needs an emergency referral, then the Medical Coordinator makes the final decision. As one Congolese employee summarised: “everything begins and ends with the MedCo. He is the first referral person and the last decision maker.”

To further argue that there were stark limitations to the staff health policy, Congolese employees highlighted two recent staff deaths, which they attributed to medical complications after delayed referrals to Goma from rural project locations. In both cases, the conclusion among many locally recruited employees was that there had been “hesitation about whether an evacuation had to be arranged or not” on the part of the Medical Coordinator and coordination colleagues, because “emergency transfer is not obtained that easily with MSF when it’s for a national staff member.” In one case, Congolese employees were under the impression that coordination had suggested that the employee “wait a bit until their day off” because their condition was not considered a medical emergency. Another Congolese employee thought that the employee had been refused an emergency evacuation and had to ask for annual leave to go and seek treatment.

Beyond the medical specificities of these particular cases, they bring into question a set of broader issues related to health referral in MSF. First, is it a conflict of interest that an employer is also one’s health provider? Locally recruited employees described an uncomfortable dependency on MSF as an employer: their managers were not only responsible for their wages, but also their access to healthcare provision, including emergency treatment. This accentuated the stark power imbalances within MSF teams. One Congolese employee concluded that MSF’s approach was like a business, in which “they need the work done more than they need the personnel.” There are “so many rules and regulations” for healthcare, they concluded, because “MSF accepts without really accepting” responsibility for all their staff.

Second, these cases raise important questions about accountability and transparency. How are decisions about referrals made, and what obligations does MSF have to its workforce to explain these decisions? Among local teams, it remained unclear what clinical governance processes were in place. It appears that the decision-making process behind these referral cases has never been explained to Congolese teams. In relation to one of the referrals, for instance, employees asked: “But what were the parameters that made you [MSF] judge that they [the colleague] could wait until the day after tomorrow?” This has echoes of the lack of transparency and communication that staff described as affecting MSF’s medical and health work more broadly.

Congolese employees were concerned about how decisions about how staff health referrals were made by a few individuals occupying coordination positions. There was clearly a lack of trust in this process, and concerns that these coordinators might have been given “bad briefings” that would lead them to dismiss their colleagues’ requests for medical help:

“For example, they are warned not to get too close to the locals in Goma. Or they are simply told to ignore the complaints of the staff. They are told that it’s not even worth noting. Because otherwise how to explain that a medical supervisor who sees his own staff sick decides to wait when they don’t even have any medicine to give. When you know there’s nothing left to do but transfer. What are they waiting for? So, it’s almost again a policy but an informal one, it’s not written but somewhere the message is well conveyed. No. The healthcare policy is there, but […] followed halfway or not followed. There are clauses that I find weird in a policy, that say we have to study each case individually. When we say this it’s problematic. It becomes the supervisor’s prerogative alone.”

Congolese employees described medical coordinators as filters between them and Amsterdam, but also questioned whether headquarters was taking sufficient responsibility. One employee in DRC, for instance, suggested that Amsterdam remained largely absent from these processes, and had not investigated the likely reasons behind the cases and the potential impact of delayed medical referrals:

“There is a policy that has been developed and approved by the headquarters, do they see what’s going on? After losing [someone], for example, did they ask themselves the right questions? Did they reassess the situation? Did they look closely at what they could do to solve the problem?”

Another Congolese employee explained:

“Now it is the first time I talk about it. I was never approached by MSF and asked about this, about whether it was normal or not, and what could be done to prevent that from happening again. We can’t stop people from dying, but we can prevent events like these […] These are not only structural challenges, they [MSF] have to take responsibility.”

Finally, while evacuations of internationally mobile staff are not necessarily straightforward (see for example McLean, 2017), the refusal of the possibility of international health care for locally recruited staff raises questions about how MSF understands the relationship between its ‘social mission’ and the majority of its personnel who both come from, and work in, the countries where MSF seeks to act on that mission. In DRC, several employees recounted a heated exchange with a former manager about the health evacuations policy: “When we confronted our manager, I don’t know if it was simply out of anger, but they said: ‘we are a humanitarian organisation for the patients, not for the staff’.” This instance was mentioned to capture the conclusions that locally recruited staff drew about their paradoxical status: the organisation focuses on saving lives – ‘the patient’ – rather than on the treatment of the workforce, even when members of the workforce come from the same communities as the patients. This appears to reflect the organisation’s emergency culture and re-emphasises the importance of the ‘suffering Other’ at the heart of MSF’s raison d’être and decision-making.

Yet care for patients, too, has limits. As an interviewee speaking in a different context commented, “the clue’s in the name, we’re Doctors Without Borders, we’re not Patients Without Borders.” At the time, they were highlighting the institution’s emphasis on defining different groups within MSF (the ‘who’ matters, as discussed in Chapter 5). However, it also suggests the boundaries of the care that it will provide to patients. When locally recruited staff become patients, these limits are exposed. As a former Head of Mission in Congo said: “Another question arises here, of whether MSF would send patients abroad for healthcare if needed. That does not happen, so why would it be done for national employees and not for patients?”

Conclusion

Coordinators hold the power to block, or to elevate, and to act as communication conduits in a vast and dispersed organisational structure. In either case, they act as filters – filtering information, opportunities, and particular policies into practice. This form of power is hierarchical, but also highly individualised. As a result, proximity to, and networks with, internationally mobile employees in management positions were seen as a form of influence by (and for) locally recruited staff. Clearly, there is a great degree of distrust among locally recruited staff in project sites towards coordinators, and a lack of clarity for many about how decisions are made in OCA. It seems that this power to filter, reinforce, or break through is a mechanism through which inequalities are reproduced within the organisation. This determines opportunities for locally recruited staff and has potential consequences for the way that staff security and health policies are put into practice.