Core to Médecins Sans Frontières (MSF)s approach to assistance is sending international staff into foreign contexts to work with, and usually direct, locally recruited national staff. Outsiders bring experience, leadership and technical skills, and are in a better position to witness intolerable situations and speak out about them. International staff are also better able to resist local pressures for resource diversion, giving MSF greater confidence that donor money is being spent appropriately. For many within and outside MSF, this model is the only responsible option because the compromises assumed to be inherent in a remotely managed programme are unacceptable. MSF-Operational Center Amsterdam (MSFOCA) s experience in Somalia challenges this paradigm, and suggests that the specific remote management model developed in this context works well and does not entail unacceptable compromises. While remote management should never be a first choice, in some contexts it can be a viable operational alternative to the deployment of international staff.
On 28 January 2008 three MSF employees, one local and two international, were killed by a roadside bomb in the Somali port city of Kismayo. The deaths prompted the withdrawal of all MSF international staff across Somalia. As the risk of deploying expatriates, at least permanently, became too great, the mission set about adapting to this new reality.
Remote management was not without precedent within MSF, but there was little documentation of lessons learnt, necessary preconditions and tools, protocols or strategies that could help guide the process in Somalia. The mission therefore started from scratch by identifying the following risks:
- Reduced control over resources, especially cash and consumable items.
- Declining medical quality.
- Limited or no programme expansion or adaptation, including emergency response.
- Increased risk to national staff, especially in senior positions.
- Impartiality could be compromised by local clan dynamics reflected in the staff corps.
- Limited or no témoignage (witnessing and speaking out on behalf of the affected population).
A system was subsequently developed to mitigate these risks, based on new and adapted tools and procedures. Gradually mission culture shifted and national staff, supported and held accountable by a mixed Somali, Kenyan and international Country Management Team (CMT) based in Nairobi, took greater ownership of programme activities.
The remote management system is based on several key concepts:
- Centralised decision-making. To maximise control over resource flows and reduce the risks to national staff in the field, most resource-related decisions that would normally be taken at field level are instead taken by the CMT.
- Micro-management and cross-checking. The Nairobi CMT is much more closely involved in project details than CMTs in most other MSF missions. Information coming from the field, especially resource-related information, is cross-checked through other sources within and across departments.
- Support and training. Field staff are brought out to Nairobi (and in some cases sent to Europe) for meetings and training more frequently and for a wider range of topics than in other MSF-OCA missions. In 2011 and 2012, staff came to Nairobi (or were sent further abroad) 116 times.
Each support department medical, logistics and finance/HR has developed new ways of working to meet the particular demands of remote management, while continuing to use the same performance indicators as any other OCA mission. Medical staff based in Nairobi work very closely with their colleagues in the field. Daily contact, through email, phone and now video, is standard in order to track developments and coach, support and advise field staff. Weekly medical and surveillance reports are submitted, mortality reviews are conducted of all deaths, referrals are done in consultation with staff in Nairobi and exit interviews are conducted to help ensure that patients are receiving proper care. Patient registers are kept in duplicate, and individual files are monitored, either scanned and sent to Nairobi upon request or checked during visits. Prescriptions are checked for accuracy as well as to compare against drug consumption, and counter-signatures are required for external services like X-rays and lab work. For the two projects where international visits are possible, checklists are created to maximise the efficiency of visits, some of which last only a few hours.
There is a similar level of contact between Nairobi and field logistics staff, particularly around supply management. Stocks are reviewed weekly with monthly physical stock counts, and stocks are tracked digitally through the shadow administration and approved from Nairobi down to hospital ward level. Medical consumption data is cross-checked with stock movement data to catch inconsistencies as well as to help avoid pipeline ruptures, for which a specific protocol is developed. Supply incident reports are written up to help learn from errors. Standard price and item lists, quotations and counter-signatures help control local purchasing, while supplier selection and payment is managed directly from Nairobi. Checklists are also used during international visits.
Financial control procedures are extensive, starting with exceptionally detailed line-by-line budget control. Staff in Nairobi approve all payments, orders and payroll adjustments. Local purchases are also approved in Nairobi after quotes have been obtained from pre-identified suppliers, using standard price lists drawn up after cross-checking prices from different suppliers in different locations. The cash is transferred directly to the supplier from Nairobi using a cash transfer order, minimising cash flow and increasing the potential for scrutiny. Receipts are sent to Nairobi on a weekly basis and analysed for inconsistencies. Checklists are also used by field staff to ensure that all tasks are completed, and to highlight any problems.
Most HR management decisions are made in Nairobi to reduce pressure on senior field staff and ensure consistency. Leave time, replacements during absences, casual labour and overtime are approved by staff in Nairobi. For unskilled staff, the mission has always asked the local administration or community elders for recruits in order to ensure an appropriate clan balance and deflect potential dissatisfaction away from MSF. For skilled staff, applicants are given an exam sent from and returned to Nairobi, and the best candidates are then interviewed from Nairobi. A rationalisation tool has also been created to allow comparison of staffing levels with current activities. Disciplinary action, including dismissal, is signed off by the Head of Mission following a process of evidence-gathering and testimonies. Training is more frequent than normal, and covers a wider range of skills and categories of staff. Training is conducted in person in Nairobi and further abroad, via distance learning and where possible on the job. Trainees are tested before, during and after their sessions.
Evaluating remote management
An evaluation conducted in July 2012 by MSFs internal resource auditor together with an external medical consultant concluded that the remote management model used in Somalia leads to relevant programs, with good medical quality and control over resources comparable to regular projects.+Sondorp and Ramshorst, Somalia Remote Management Evaluation, September 2012, p. 2. The extra checks and balances normally conducted by international staff in the field are largely compensated for by strong remote management procedures and extra scrutiny, and there is no systematic leakage or corruption on a noticeable scale. On the financial side, the evaluation concluded that control of financial resources was better than in many normal missions, and that warehousing procedures and stock management were of a high standard. The quality of medical care was found to be comparable to, and sometimes better than, other MSF missions. Where dips in quality were observed corrective measures were applied. In terms of programme expansion and emergency response, since remote management started, two new hospital wards have been opened, as well as an under- 12 out-patient service. Teams have managed a measles vaccination campaign, responded to measles, cholera and flooding emergencies within and outside existing facilities and scaled up to meet the spike in malnutrition during the 2011 famine, including in al-Shabaab-controlled areas. It is difficult to measure the degree to which national staff are at increased risk due to remote management, but locating resource-related decisions in Nairobi appears to have had a positive impact and so far there have been no major security incidents involving national staff.
It is equally difficult to measure the impartiality of our staff, although there is no evidence from exit interviews and patient register scans that particular groups have been excluded from assistance or discriminated against on clan or ethnic grounds. Témoignage is to some extent compromised by not having regular international staff presence on the ground, but the mission has nonetheless endeavoured to maintain a strong advocacy agenda. At the international level, the mission has been prolific in communicating to the public and to foreign governments about the condition of Somalis and the inadequate assistance they receive. In 2011, the mission produced over 40 public pieces including specific communications protesting against abuses faced by local civilians. And in Lower Juba, national staff successfully lobbied al- Shabaab for the expansion of activities during the crisis phase in 2011 (four new locations), passive vaccination and the return of confiscated therapeutic food.
The success of remote management in Somalia seems to be based on three key elements: a rigorous and transparent control system; the competence of national staff in the field, and their familiarity with MSFs principles and ways of working; and the high degree of ownership amongst national staff, who have a real stake in the missions success and are motivated to go well beyond simply executing tasks. The remote management system is not airtight and improvements are continuously sought. Consumption data is now being cross-checked with stock movements at a more detailed level, and improvements are underway in prescription tracking, invoicing and staff evaluations. Video links are offering new means for recruitment, coaching, meetings and telemedicine. The systems greatest strength, though, is not in the procedures as such, but in the culture shift that has realigned roles and responsibilities and instilled a strong commitment at all levels to make it work.
Should remote management be adopted elsewhere? One factor that may be critical to the success of this approach in other contexts is the pre-existence of programmes with international staff in the field. National staff in Somalia were already familiar with MSF principles and protocols, and with absences of international staff due to insecurity, and this laid the groundwork for a shift to remote management that may not have been possible otherwise. The best we can say is that it is an acceptable system as it is currently implemented in Somalia, where the mission achieves very high impact in what is still one of the worlds worst humanitarian crises.
Joe Belliveau is Operations Manager at MSF-Operational Center Amsterdam.