Diagnostic Disconnects
This chapter looks at some of the reasons staff give for why, in their eyes, MSF struggles to act on its stated ambitions to change power dynamics. It looks at understandings and beliefs that impact the space and motivation for action.
Key Findings
Staff believe MSF is “glacially slow” to address problematic power dynamics and inequalities.
Paternalism, ethnocentrism and a lack of vision for change are among the aspects of MSF culture that staff see as explaining why it struggles with reforms.
Staff believe that those in perceived positions of power want to maintain their dominance. This has motivated some people to develop their own initiatives to contribute to change, while the perceived lack of change has also led to employees disengaging with ideas for reform.
“There are countless examples like this one, where we have expressed an intention but we cannot seem to cut the Gordian knot of our own rules and regulations. As a consequence, little of substance appears to be happening while I know for a fact that there is genuine intention.”
Chapter overview
There is a widely stated opinion that MSF is “glacially slow”
– in the words of one senior manager – This chapter introduces five narratives about MSF’s nature:
1. Paternalism
Paternalism in MSF is frequently mentioned in criticism of an unwillingness – and even inability – to give up power and perceived insincerity in committing to reform. The Person-Centred Care initiative is given as an example of an initiative being “more talk than action”, with one interviewee saying: “I’ve heard a lot about it [PCC], but in terms of implementation, again, because it’s done in a very ad hoc, piecemeal, unstructured manner I’ve not seen a lot of implementation.”
2. Ethnocentrism
MSF’s approach is imagined to be universal, but in reality, it’s centred around white Eurocentric cultural norms. Many employees commented on Western bias in operational standards, and racialised ideas about professionalism.
Some conclude that MSF is ‘ethnocentric’, ‘Eurocentric’, institutionally racist, or even white supremacist. Some worry that lack of representation could be linked with inappropriate or poorer quality of care for black and brown patients.
Yet the concept of Diversity, Equity and Inclusion (DEI) brings its own problems. Nearly everyone interviewed about DEI – in every setting, at every level, and in all types of roles – rejected the idea that DEI can be universally applied, and criticised Western ethnocentric and top-down approaches. While locally recruited staff, in particular, emphasised the risk of DEI becoming another concept imposed from headquarters, others criticised what they saw as a failure to stand up for these very same values.
3. Lack of vision for change
MSF struggles with large-scale visions for change, both with its relationship with political issues and with internal dynamics. Some see this as a problem, while others see it as important to place limits on the scope of action.
The weakness of politically informed visions of MSF’s potential roles or actions is linked to the size of MSF, and the splintering and bureaucratisation that goes with it. What’s more, an institutional culture that emphasises debate and participation also contributes – even if in reality these are limited by power dynamics and inequities.
Is change even possible? Some interviewees at headquarters level (particularly those with extensive or high-level experience) believe that ambitious changes to the way MSF works are difficult, undesirable, or both.
4. Lack of appetite for change
As well as believing MSF lacks a clear vision for organisational change, many employees believe it lacks appetite for change.
There was a sense that:
- MSF is avoiding structural and other complex issues
- There is a gap between rhetoric and action
- Practical change needed to begin higher up
Staff strongly believe that those in perceived positions of power, whether formal or informal, want to maintain their influence. The lack of appetite for change therefore relates specifically to change that would address internal inequities and injustices.
As an example of a complex issue, interviewees raised the exclusion of locally recruited staff from senior positions in their country of origin – though they did point to the rising proportion of internationally mobile staff from the ‘Global South’ as a sign of increasing inclusion. However, while this greater access to international mobility improves the outlook for individual employees, it doesn’t address the systemic issues of locally recruited staff as a whole.
Some staff question the sincerity of MSF’s stated commitment to addressing injustices. They believe that naming the problem and making commitments to improving it stands in for taking concrete action. It allows MSF to be seen to be doing something, so that it can’t be accused of inaction, but allows it to ignore complaints brought forward through other pathways.
Frustrated by a lack of action, “people get disenfranchised”, withdrawing their participation from surveys, consultations and research.
5. Action-oriented
MSF’s appreciation of individuals who drive change is an important exception to critiques of leadership – though people don’t need to be in positions of formal power to be perceived as leaders in this sense.
OCA programme staff describe an “unrealistic” succession of agendas that inflate their workload. One employee mentioned that these are often whatever topic is deemed “trendy”: “At one point it’s patient-centred care, at another point it’s employee engagement, at another point it’s the climate…”
When staff believe action is being avoided or blocked, they adopt disruptive approaches to change rather than accepting the status quo or relying on incremental change. In OCA, for example, the Kaleidoscope Network and the Rainbow Network were both formed by small groups of staff members based in the Amsterdam office who felt there was “absolutely nothing happening on the part of the [Management Team] whatsoever.”
Interviewees describe an organisational culture strong on reaction or improvisation, but weak on approaching structural issues. The emphasis on individual initiative underpins the idea that “you need people who’ve got the conviction and passion to just really keep pushing on a topic.”
There is a habit of thinking that there are “quick wins” in relation to inequalities within MSF, but also a perception that they are not always exploited. Another reflection of emergency culture, the idea of quick wins can be contrasted with what’s needed to tackle more challenging structural issues.
Action like this can contribute to positive steps, but it also risks increasing the burden on individual staff in an already demanding workplace. There were, however, some cautious, qualified observations that expressed hope for the prospects of improvement.
Delve deeper
Image credit:
17. Nasir Ghafoor/MSF
18. Mohammed Sanabani/MSF
19. Michael Lunanga/MSF