MSF in Borno, Nigeria: taking a critical look

In 2016, the Operations Department commissioned a review of Médecins Sans Frontières (MSF) France’s operations between 2015 and 2016 in Borno State in north-eastern Nigeria, in response to the consequences of the conflict between the government and Boko Haram. As part of the project, some of the directors and operations managers who had been involved reflected on their experience: were we late in responding to the catastrophic situation in IDP camps in rural areas and on the outskirts of Maiduguri, the state capital, in 2016? If so, why? What conclusions can be drawn about the operational choices made and the effectiveness of MSF’s intervention strategies? And what does this experience tell us about how MSF functions and how our teams work?

[Interview with Isabelle Defourny, Operations Director at MSF-OCP]

 Why was the review commissioned?

When, in June 2016, our teams arrived in Bama – a town 70km away from Maiduguri, where 20,000 displaced people had gathered in the grounds of a hospital controlled by the Nigerian army – they were stunned to find a catastrophic health situation. Mortality rates were 10 per 10,000 per day, with 1,200 graves in the hospital grounds testifying to the scale and duration of the crisis.

Just a few months earlier, in January, the health situation in Maiduguri had appeared to be under control: a cholera outbreak had ended and mortality and malnutrition rates were back below emergency thresholds. We believed that, while the situation in the localities around Maiduguri controlled by the Nigerian government – like Bama – was probably not very good, we certainly weren’t expecting things to be as bad as they were. And yet other humanitarian actors, including UN agencies, the ICRC and ECHO, had known about the situation outside the city for some time. Back in September 2015, the ICRC had identified severe malnutrition rates of 25% in the camp in Dikwa.

Hence the question: how did we not know about the scale of the crisis when everyone else did? We knew there were large numbers of displaced people in Bama, but security problems made the town difficult to reach; the Nigerian government was hiding the gravity of the situation and the ICRC was not talking about it openly. These were real constraints – but even so, if we’d paid more attention to what other actors were documenting, we could have been in Bama by April, saving two months. Assessments produced by the UN and WFP should have rung the alarm if we’d been more open to what colleagues from the UN were saying – even if, for political reasons, the seriousness of the situation was not explicitly stated.

Another issue was the analysis of the context during the handover from the emergency cell to the regular cell, which wasn’t thorough enough. For example, it is revealing that there is no written analysis of the situation in north-eastern Nigeria during this period. This is a criticism that I also direct at myself because, as Operations Director, I could have asked the emergency cell to provide more detailed analysis of the context after spending a year working in Borno. If I had, we would probably have got an answer, perhaps along the lines of ‘the health situation in Maiduguri is under control but we don’t know what’s going on outside the city – we haven’t been out there’.   I don’t know to what extent the high volume of activities carried out by MSF in Maiduguri contributed to the delay in responding to needs outside the city, particularly in Bama. Perhaps we could have scaled back activities in the town earlier, given that health indicators had improved significantly, and redirected our attention and resources to Bama.

In all large-scale emergency operations there are always management problems, which can create opportunities for misappropriation. This is neither surprising nor insurmountable. The real problem in Borno was not misappropriation as such, but the fact that it was never mentioned and, worse still, was not dealt with. During an emergency deployment, the case number curve and human resources curve are never in phase because it takes time to find the right people and then make sure they’re available, get visas and so on. So, during the initial phase, there are often not enough people to cope with the scale of an emergency, which can lead to management problems. There comes a point where more human resources are available but the situation has become less serious, with a decline in mortality rates and fewer cases of cholera and malnutrition. This is the time to sort out any management problems and deal with any incidents of misappropriation, for example.

 How can we do better?

All our missions, but especially emergency missions, have problems producing consolidated and collective situation analyses in time to help us make the right operational choices. In concrete terms, we need to improve our ability to produce written summaries of the different perspectives provided by the field, HQ, the coordination team, the cells and the Operations Department. Despite numerous difficulties at all levels (MSF’s size, constant staff turnover, a ‘silo mentality’ in departments), we must be capable of drafting and supplying proper analysis in the various documents we circulate, such as field visit and situation reports. Operational managers should then produce a document that reflects any differences of opinion in these analyses, with no points of view overlooked or ignored. In emergency missions, where we have little time for in-depth situation analyses, where security problems are common and operational choices rarely simple, an explanation of these different points of view and the reasons for them is needed to legitimise the decisions we eventually choose to implement – on issues such as whether or not to accept an armed escort to visit Bama, for example – and provide teams with clear direction.

Experience in Bama shows that recommendations made during field visits by very experienced support staff from HQ are not always actionable by teams in the field given their workload and the resources available at the time. So there is no point giving them long lists of recommendations, even if everyone agrees that, in theory, it should be possible to implement them all. Given their experience, these support staff are probably best placed to implement their own recommendations, but they are rarely involved in this side of things. They also sometimes dodge the hard calls: listening to the field and then making choices, taking risky decisions even if in retrospect they turn out to be the wrong ones – this is the operational managers’ role. Otherwise, the danger is that they’ll do little more than note that what they asked to be done in the field was not done, and what should be support to these teams gradually turns into control of their work.

We manage to carry out food distributions, vaccination campaigns, malaria prevention and treatment, all of which are essential in disaster situations, but we find it difficult to effectively transition from these mass operations to others that could be described as more subtle, and that focus on the most vulnerable among the vulnerable. If we want to know what’s happening in the areas where we work, we must talk to the people living there. It is the role of every team member to understand what is happening with these people and to check that the relief we’re offering is appropriate. In Bama, I think we could have done this at an earlier stage – talk with the women in the camp, try to understand the context of violence they were living in and identify any new medical issues. The review of MSF’s operation in Borno pointed out that the psychologist was the only person to raise the issue of violence and talk about the reality of the people living in the camps.

While there is no doubt that MSF provided much-needed assistance to hundreds of thousands of displaced people in Maiduguri, there are a number of lessons we can learn from reflecting on our response to the wider crisis in Borno State. First, we need to improve and regularly review and update our analysis of each context to ensure that responses at different points in time are appropriate.  This should include paying more attention to what other actors, including the UN, are doing and saying.  In addition, we need to improve decision-making by documenting and analysing the different perspectives from the field, HQ, the coordination team, the cells and the Operations Department. Second, HQ support staff need to take more responsibility for implementing their own recommendations rather than leaving this to field staff. Last, and most importantly, all staff need to talk to affected people to try to understand their circumstances and needs and ensure that our response is appropriate.

Elba Rahmouni, dissemination officer at MSF CRASH