They constantly try to escape from the darkness outside and within by dreaming of systems so perfect that no one will need to be good.
T. S. Eliot, The Rock
There is no question that humanitarian organisations must be accountable, both in the sense of giving account and being answerable for the choices they make, the work they do and the resources they use. Nor is it debatable, given the often poor response to crises and the lack of transparency about results obtained, that far more accountability is needed. The issue is rather to whom, about what and for what purpose. Accountability has become a global buzzword. Since Austen Davis report, published and presented at ODI in 2007, MSF has looked into this issue with the conviction that a specific approach needs to be developed, reflecting the reality and the challenges of field-based medical humanitarian work (Austen Davis, Concerning Accountability of Humanitarian Action, Network Paper 58, 2007). This article describes this approach, as well as presenting MSFs present practice with regard to accountability.
Proliferation of accountability efforts: challenging an unquestionably good idea*
NGOs like MSF are by definition self-mandating. Constituted by people who come together in pursuit of an agreed goal, they define themselves by what they aim to achieve and how they intend to do it. In carrying out their social mission, they are dependent on at minimum the acceptance, and at best the support, of a broad range of constituencies, ranging from local authorities and communities to donors and the general public. Responsiveness to these stakeholders occurs in many ways, yet operating transnationally across different jurisdictions, NGOs are only partly subject to formal accountability mechanisms, for instance mandatory financial reporting related to their tax-exempt status (Dorothea Hilhorst, Being Good at Doing Good? Quality and Accountability of Humanitarian NGOs, Disasters, 2002).
This unregulated nature of NGOs, compounded by the humanitarian sectors heightened political profile in the international response to crises, a rising number of aid organisations and an increase in available funding, provides the backdrop to growing calls for humanitarian organisations to improve their accountability. At least three different strands can be identified. The first focuses on setting general or technical standards, such as the Code of Conduct and Sphere. The second category has its origins in the corporate sector and introduces concepts like results-oriented management and the certification of (humanitarian) organisations which comply with set norms and processes, such as the One World Trust. The third, exemplified by the Humanitarian Accountability Project, centres on the rights-based approach, positing that humanitarian organisations have obligations, particularly towards those they aim to help (accountability to beneficiaries).
Together, these initiatives constitute a significant, largely donor-driven effort to improve accountability. Although they include promising and important elements, MSF has two main concerns. The first relates to the definition of humanitarian assistance and the role of humanitarian organisations. Increasingly, humanitarian action is viewed as an integral part of a comprehensive international effort to respond to crises, contributing to peace, state-building and reconstruction (Eric Stobbaerts, Katharine Derderian and Sarah Martin, Integration and UN Humanitarian Reforms, Forced Migration Review, October 2007). Calls for increased accountability are closely associated with efforts to increase the coordination of humanitarian organisations and strengthen their links to broader international agendas (See Nicolas de Torrenté, Humanitarianism Sacrificed: Integrations False Promise, Ethics and International Affairs, 2004).
The second concern relates to one size fits all or global solutions approaches to accountability. These provide little space for understanding the particular responsibilities of humanitarian organisations and the challenges encountered in the volatile, politically charged and violent contexts in which humanitarian action takes place (Pierre Perrin, Accountability: A Framework, FORUM: War and Accountability, ICRC, 2002). Similarly, they often fail to create innovative and adapted organisational models for management, monitoring and evaluation (Sally Bibb, The Stone Age Company, Marshall Cavendish Business, 2005). Insistence on measurable indicators, while important, may underplay aspects of humanitarian action that are harder to quantify, such as the relevance of the aid provided to peoples actual needs or the value of humanitarian organisations presence for advocacy purposes. Rights-based approaches also fail to recognise that individuals subjected to violence and neglect may be prevented from exercising the very rights through which they are expected to hold humanitarian organisations to account.
As humanitarian accountability is seen as an unquestionably good idea, challenging initiatives to improve it may seem ill-advised. However, by defining accountability in such general terms there is a risk that it will remain merely a buzzword or become an end in itself. Indeed, it is unclear if any major improvement in the relevance and quality of the humanitarian response has been obtained from current accountability efforts. Ultimately, their principal effect could be to expand bureaucratic mechanisms and tie humanitarian action more closely to an increasingly coordinated response to crises, potentially undermining the specific contribution that humanitarian assistance can make for those most at risk.
Developing a specific approach
MSFs approach to accountability is based on four key tenets. First is the specific responsibility that a medical humanitarian organisation assumes in carrying out its work. We consider that we are accountable for what we set out to achieve and the means that we employ. Second, our approach to accountability aims to be realistic and realisable, taking account of the fact that, frequently, the contexts in which we work offer only bad choices. Third, we seek to recognise the diversity of constituencies that have a stake in our medical humanitarian work and to address their particular needs and interests. Finally, accountability is conceived of as a learning process. Mistakes will be made and failures will recur as humanitarian aid is a real-time response to acute needs in exceptional circumstances, requiring risk-taking, innovative approaches and difficult judgments.
Specific areas of focus
MSF is currently focusing on three specific areas of accountability: to beneficiaries; to donors and the general public; and mutual accountability within different parts of the organisation.
Beneficiaries, patients and communities
Downstream accountability to intended beneficiaries is the most difficult to define and the hardest to achieve. As a medical organisation, medical ethics are the starting point in our relationship with patients. Medical ethics also provide useful points of reference in highlighting instances where patients interests should take precedence over policy or legislation. However, medical ethics do not constitute a clear guideline. Not only are there different ethical approaches, but different ethical values often clash and require arbitration. Finally, medical ethics only address health-related matters, whereas humanitarian catastrophes engulf peoples entire lives.
A broader group than patients are those to whom our assistance is addressed.** The accountability to beneficiaries approach emphasises consultation with or the participation of the recipients of assistance, who are defined as rights-holders (Jean-Herve Bradol, How Images of Adversity Affect the Quality of Aid, in Marc Le Pape and Pierre Salignon (eds), Civilians Under Fire Humanitarian Practices in the Congo Republic 1998-2000, MSF, 2003. We have learned firsthand that not listening to those caught up in conflict can result in a stereotypical response that fits our preconceived notions of the ideal victim and our organisational priorities, rather than actual, pressing needs. For instance, we failed for years to detect and treat sexual violence, a critical yet largely invisible need if women are not actively sought out. However, participation and consultation are not always feasible. Particularly in conflicts, the seriousness of their predicament means that victims cannot simply be equated with clients or patients in stable settings. Inherent in international humanitarian law is the notion that the powerlessness of victims is precisely what entitles them to protection and the provision of assistance (Francoise Bouchet-Saulnier, The Practical Guide to Humanitarian Law, 2007). Furthermore, the notion that vulnerable crisis-affected people are able to articulate what they require from aid organisations ignores not only power relations within societies but also the benefits that local leaders often intend to obtain from the aid relationship. Those who speak for the community frequently have little interest in those who most need help.
Rather than wish away these important limitations, we would rather assume clear responsibility for determining the aid we provide based on an open-minded and empathetic assessment of peoples needs and our ability to meet them. The starting point is that the process of negotiation whereby humanitarian actors gain access, define programmes and maintain an acceptable space of work should entail as much transparency as feasible, both about the choices made and the limits of our ability to assist. MSFs experience in more stable settings has been particularly important in this respect, in particular HIV/AIDS treatment programmes, where a long-term relationship with patients and patient groups and patient education and empowerment are key. This has challenged the top-down approach often typical in emergencies and made us understand the importance of actively explaining the rationale for decisions like the opening and closure of programmes, although there remains significant room for improvement.
Donors and the public
Upstream accountability towards donors and the general public is a more developed area. Financial accountability in particular has received considerable attention. Within MSF, the financial resources supporting programmes are pooled from different offices; a commitment to increased transparency has resulted in the establishment of international combined financial accounts for the entire MSF movement, certified by independent auditors. This is something of a first for a large network of independent yet interdependent aid organisations.
Financial accountability often focuses on proper accounting, fraud prevention and internal controls, but measures of efficiency pertaining to the allocation and use of resources have limitations. While MSF can boast a favorable 82% social mission ratio (the proportion of resources allocated to programme activities against fundraising and administration), this is an imprecise and potentially misleading measure. For instance, raising private funds (which constitute more than 85% of MSFs resources) is more costly than applying for grants from governments, which means that aid organisations relying more heavily on government funding may score better. And ironically, as all programme expenses are considered positive, even inefficient spending in the field for instance sending supplies by charter plane instead of by boat as a result of poor planning improves the social mission ratio. Beyond financial accountability, organisational accountability indicators comparing staffing levels at headquarters versus field level do not readily exist, and comparisons with other types of health service organisations like hospitals are problematic given the transnational, non-profit and mission-specific nature of our work.
Measures that efficiently orient the provision of resources to programmes are therefore required. Rather than rigid ratios, what is needed is a measure of resources per activity that would allow reporting, and budgeting, based on specific input/output ratios rather than the general functional categories currently used (staff, transport, medicines, etc). While MSF has started to implement such activity-based reporting and budgeting, there is still much to be done before this approach can be systematically used to report or forecast expenditure on a programme-wide or organisation-wide basis.
Assessing the effectivenesswith which resources are used requires not just a description or accounting of activities, but also of outcomes. The results of our medical work (e.g. patient cure rates) are currently available for a limited number of programme activities such as HIV/AIDS, malaria, nutrition and surgery. This type of results reporting should be expanded, taking into account the inherent difficulties of measuring outcomes, attributing causality and the additional burden of work for field teams.
An increasing focus on results is closely linked to another MSF priority greater transparency about the difficulties, shortcomings and limits of medical humanitarian work. This includes being critical and reflective about the outcomes achieved, including where underachievement is due to internal problems. The intention is to integrate this commitment to openness into donor mailings, websites and information to the general public. MSF believes that supporter trust is built on a nuanced portrayal of reality, despite the temptation to promote ones achievements as donors naturally respond to stories of success.
Governance and mutual accountability within the MSF movement
The third area of focus for MSF is primarily internal. Mutual accountability is the critical review of operational approaches and outcomes between the different MSF operational centres (OCs). MSF has opted against a pyramid structure with an overarching authority. However, diversity must be complemented by a commitment to evaluating different strategies and their outcomes, including the pros and cons of different OCs working in the same context. MSFs international office has therefore been tasked with further defining a methodology and carrying out comparative assessments. This commitment to openness may in the future lead to the involvement of external auditors. Another important area which should be further assessed is MSFs advocacy and communications work.
Finally, mutual accountability is also closely linked to governance, whereby those bodies charged with guiding and overseeing MSFs work are provided with the information they need to discharge their duties. MSF national sections are organised as associations, with members owning the organisation and electing their peers to the Board of Directors. In turn, the Presidents of the Boards of the 19 sections form the International Council, MSFs highest body. Information-sharing and critical reviews of operations are essential for Boards to be able to hold executives to account.
More accountability is required in the humanitarian field, and progress can and must be made. The quality and extent of aid provided to people affected by acute crises is frequently insufficient, and the trust and support required by humanitarian operations on a number of levels need to be actively nurtured. Confidence in humanitarian organisations and the values they claim to stand for has eroded in many parts of the world. Yet it is important to tie discussions about accountability to the specific responsibilities of humanitarian organisations our objectives, activities and the conditions in which we work. In our experience, a useful way forward centres on ongoing and critical reflection about the responsibilities, limits and meaning of humanitarian action in concrete situations.*** Developing a specific framework for accountability on this premise may be more productive than adopting overly broad or ambitious initiatives that risk becoming either empty slogans or burdensome bureaucratic processes.
While we can learn from other sectors, the illusion that humanitarian action will ever be perfectly objective, governed by rules, standards and procedures, is dangerous. This is particularly the case when these norms are set and required by political entities. Humanitarian action by definition exists in tension with the status quo, with mainstream political norms and the choices that have led, and continue to lead, to the neglect and victimisation of large parts of society. ARV therapy for people living with HIV/AIDS was certainly not the international standard at the start of the twenty-first century, nor was treating malaria patients in Africa with ACTs up to very recently. Adopting donor-driven accountability measures could end up binding humanitarian organisations ever more closely to broader government priorities and choices in crises, instead of improving the relevance and effectiveness of humanitarian work. And while relevant concepts from the private sector are welcome, humanitarian aid is not a market with consumers and service providers. There is an inherent element of field craft, even arbitrariness, in operational choices, and this has to be acknowledged and explained.
Ultimately, accountability is perhaps most significant as an organisational state of mind a willingness to ask difficult questions about ones operations, to seek and share the answers, and to learn from the process. Recent events in Myanmar are a good example of this état desprit: rather than foregone conclusions based on set standards, critical questions were asked within MSF about the risks posed by the denial of access for international staff to field sites, drawing upon previous work in the country and under other repressive regimes. Monitoring systems adapted to the situation of national staff delivering the bulk of assistance were also put in place, assuaging concerns that the restrictive operating environment might lead to intolerable outcomes in terms of aid delivery. The aim here, as in other situations that are by definition unacceptable, is constant progression rather than impossible perfection.
Nicolas de Torrenté is Executive Director, MSF-USA. Eric Stobbaertsis General Director, MSF-Brazil.
* Austen Davis, Accountability in Humanitarian Action An Unquestionably Good Idea. For Radical Reform? Or Utilitarian Takeover?, Discussion paper for MSF, March 2006.
** Rather than beneficiaries, which presupposes that the people whom aid organisations strive to help do indeed benefit, it would be more appropriate to call them addressees of assistance. Rony Brauman, personal communication.
*** In that regard, MSF has a number of internal reflection units notably the CRASH, centre de recherché sur laction et les savoirs humanitaires, based in Paris, whose recent work has included a book on the Niger nutritional emergency of 2005. Jean-Hervé Jezequel and Xavier Crombe (eds), Niger: une catastrophe si naturelle (Paris: Karthala, 2007).