Médecins Sans Frontières (MSF) has been sceptical about the ‘localisation agenda’, tending to see it as at best another buzzword, and at worst as a way for states to co-opt independent humanitarian action.
At field level the concerns have been more practical, particularly in cases where working in collaboration or partnership with local actors might be more effective than direct implementation, especially in difficult-to-reach areas. MSF is already collaborating with government, non-governmental and community responders. In fact, collaboration is more the rule than the exception: three-quarters of current OCA field projects feature some kind of collaboration, usually a partnership with a Ministry of Health.
The five cases
To look in more detail at MSF’s approach to local collaboration, OCA reviewed five cases:
- Cox’s Bazar in Bangladesh, where MSF worked with local authorities and local non-government actors to respond to the mass influx of Rohingya refugees from Myanmar.
- Sulaymaniyah in Iraq, where MSF worked with the Sulaymaniyah Emergency Hospital to reduce mortality in the emergency room and intensive care unit in an area affected by conflict and displacement.
- Niger and Zamfara states in Nigeria, where MSF worked with national and local government authorities and communities, technical experts and INGOs and their partners to treat victims of lead poisoning from mining.
- Deraa in Syria, where MSF remotely supported four hospitals in opposition-controlled areas to provide trauma surgery and other medical services.
- Sanliurfa in Turkey, where MSF worked with four local and national NGOs to provide healthcare to Syrian refugees.
In each case, MSF’s attitude towards local actors varied, but was mostly pragmatic and focused on short-term effectiveness, rather than being based on values or longer-term strategic goals.
MSF formed relationships with local actors because the specific project could not be accomplished without them, principally for reasons of access and acceptance. In three cases, MSF sought to start programmes in areas it did not yet have access to, and considered this possible only through working with a local actor:
- In Turkey, MSF lacked the legal registration to work independently.
- In Syria, restrictions on crossing the border with Jordan and security concerns inside Syria made it impossible for MSF to work independently.
- In Iraq, there were functioning government health facilities in the locality, and it therefore made no sense to work in isolation.
In the two other cases, in Bangladesh and Nigeria, MSF was already working independently, but access and acceptance considerations were also key factors in the relationships formed with local actors:
- In Nigeria, MSF needed the acceptance and direct involvement of local actors (both government and the community) to rehabilitate land contaminated by lead poisoning and encourage safer mining practices. MSF partnered with two specialist organisations, both of which worked with the responsible government ministries.
- In Bangladesh, MSF focused more on meeting the requirements and expectations of the authorities, coordinating with government health officials and sharing information. There were also small-scale collaborations with national NGOs for specific medical and water and sanitation activities.
As with any programme, regardless of modality, the principal problem MSF’s medical teams faced was determining what the standard of quality of care should be within a collaborative effort. Teams found it difficult not having direct management control over staff, which meant that they could not directly apply MSF’s quality standards, systems and ways of working.
- In Iraq, MSF medical teams worked with Iraqi medics to improve the quality of care provided in intensive care and emergency units by revising clinical protocols, providing training and supervision and improving technical processes. However, MSF had few management tools at its disposal and certainly did not have the authority to dismiss poorly performing staff (in a highly politicised health system the hospital director didn’t have that authority either). This, coupled with high turnover of Iraqi medical staff, significantly affected MSF’s ability to improve clinical practice.
- In Nigeria, MSF teams were initially unused to working so closely with local governments and communities. This was in contrast to its NGO partners, which were much more experienced in partnership-building. This meant that at times MSF teams sought tighter control over activities, such as representation and security procedures, which partners found unduly restrictive. Furthermore, partners reported feeling the need to re-convince each new MSF team of the need to work with local authorities and communities. Nevertheless, MSF teams were able to learn and adapt.
- In Syria, the main obstacles were connected to the remote nature of the programme. Progress accelerated significantly towards the end of the programme as relationships deepened between MSF medics in Jordan and local medics on the Syrian side of the border. Connections to communities were particularly important in improving trust and accountability with local hospitals.
- In Turkey, MSF’s capacity-building role was appreciated by the local NGOs it worked with. The main challenges were related to partner choice, as several local NGOs had limited internal capacities and MSF had little experience of managing the accountability requirements of a partnership-based programme. MSF medical staff also found it difficult to provide clinical supervision to staff managed by a local partner.
- In Bangladesh, teams differed considerably in how much effort they felt they should expend on relationships with local actors, with some teams strongly favouring it and others not seeing the need, benefit or importance. This was a major reason why the level of collaboration with local actors remained relatively underdeveloped.
The major issue MSF faced in these relationships was the absence of a coherent approach to the power dynamics inherent in any collaboration, especially those related to accountability between partners. Not being fully ‘in control’ could be confusing, leading teams to sometimes be too heavy-handed, and sometimes too accommodating.
These difficulties in management and approach were exacerbated by financial, logistical and HR systems, policies, procedures and standards that provided minimal space for working in collaboration or partnership with actors using different systems. This led to difficulties in assessing and understanding how other organisations or government agencies worked, and problems connecting to them. In some cases, teams developed their own tools and guidelines for managing these collaborations; in others, lengthy discussions were required between HQ and field teams before agreement was reached on what the policy should be in a particular case.
There will presumably be situations in the future where the requirements of the context, whether related to access or the nature of the health problem being addressed, will push MSF towards collaborations and partnerships with local actors. The research shows a willingness on MSF’s part to remain flexible and open to such approaches.
In all five cases, MSF paid insufficient attention to how to collaborate effectively. MSF needs to agree guidelines for why and how it enters into collaborations, develop tools for managing them and adjust internal systems to ensure that they can accommodate different modes of working.
The research also shows that MSF needs to address how it sees itself. Its strong sense of purpose and principle has helped it build highly effective technical and institutional capacity. But it has also constructed an overly rigid and ideological definition of its identity. All MSF staff place high value on independence and proximity, and this translates into a strong commitment to the direct provision of care, without necessarily any agreement on what exactly ‘direct care’ means.
Collaborating with local actors is not a threat to MSF’s humanitarian identity and principles, but rather a tactic which, in certain circumstances, can aid their fulfilment. Beyond arguments about effectiveness, there are good ethical reasons for working in collaboration with local actors, which are often deeply connected to their communities; working with them is often seen by communities as more respectful of their dignity and autonomy.
MSF places a high value on the principle of independence, and justifiably so, as its ability to act outside of the strictures of governments or donors is a key enabling factor in its responses. But independence has never meant isolation or disconnection from local authorities, civil society or communities themselves. Nor does it mean freedom from accountability. Rather, a humanitarian organisation should seek no more and no less than ‘the autonomy it needs to enable it to act in accordance with the [humanitarian] principles’. The criteria for judging, therefore, is whether a specific collaboration allows, or prevents, MSF from acting in a humanitarian and impartial way.
MSF similarly privileges proximity to its patients and their communities. But this is not necessarily threatened by collaboration in itself, as by the constraints within which some collaborations take place, especially when access restrictions and insecurity force a remote approach. In many situations and partnerships, MSF will be able to provide medical care to patients directly, or at least be present at the point of care. In other situations, collaborating with local actors may improve MSF’s proximity if those local actors have stronger community connections and can facilitate MSF’s work within that community. In yet others, MSF cannot be present and can only work remotely. In these cases it will have to balance loss of proximity against other possible benefits.
Finally, MSF deeply values the dignity of its patients and their communities – and, in the Chantilly Principles, extends this explicitly to include ‘helping them regain control over their own future’. Local response capacities should be seen as an essential component of communities’ attempts to regain control; supporting them is therefore an entirely legitimate component of the humanitarian mission.
 Jean Pictet, Commentaries on the Fundamental Principles of the Red Cross, https://www.icrc.org/en/doc/resources/documents/misc/fundamental-principles-commentary-010179.htm.
 The Chantilly Principles were adopted by the MSF Movement in 1995 as a unifying statement of common belief after the Rwanda crisis; see association.msf.org/sites/default/files/documents/Principles%20Chantilly%20EN.pdf.
The study reported on here was undertaken by the Operational Centre Amsterdam, part of MSF