Issue 45 - Article 12

Perception and acceptance at community level: the case of MSF in Yemen

December 16, 2009
Saleem Haddad, MSF-UK

Médecins Sans Frontières (MSF)’s approach to delivering aid is based on obtaining ‘acceptance’ of its work from the population, authorities and communities concerned. Acceptance here means that MSF seeks a social contract whereby its presence is respected by all parties to a conflict, including civilians, who all understand and accept that MSF’s humanitarian identity is central to its operations, and that MSF is there to assist those in need of emergency medical care.

In practice, this approach is more complicated than it first appears. A lack of awareness of how we are perceived is proving to be a growing impediment to the effective implementation of programmes. This may lead to security risks and reductions in access and services. Although looking to the population for a better understanding of how NGOs are perceived might seem obvious, it has taken the humanitarian community a long time to put this into practice. As humanitarians, we lament the fact that some dislike our presence, and spend much time and energy debating why this is so. Gauging perceptions and determining how to gain acceptance at local level, however, often means doing a lot less talking, and much more active listening.

In 2007, MSF set up a project providing emergency medical care to Somali and Ethiopian refugees arriving by smuggler boats on Yemen’s southern coast.[1] A year after the start of the project, two months were spent assessing how local Yemenis perceived MSF and its work, with the intention of modifying parts of the programme and implementing a communications strategy to address misperceptions. What follows is an account of how community perceptions were measured, and what steps were taken to address these perceptions.



The acceptance study had three objectives: (i) to improve MSF’s understanding of the context – global, national and local; (ii) to gain a better understanding of how local Yemenis perceived MSF; and (iii) to use this knowledge and understanding to outline steps to improve MSF’s communication with and acceptance by the local community.

Experts on Yemen were consulted and meetings held with tribal experts at the University of Sana’a. Based on these consultations, tribes were mapped by geography and lineage. Groups were organised with national staff to discuss their perceptions of community reactions to MSF’s presence in southern Yemen. Semi-structured interviews were also carried out with key authorities, including local council leaders, provincial tribal leaders and the local imam.

Following a brief discussion of MSF’s history and principles, a broader discussion with national staff and key authorities took place on the concepts of neutrality, impartiality and independence. Open-ended questions were also asked, such as ‘how is humanitarian aid and charity understood locally?’ and ‘what kind of information would you like to have about organisations working in your community?’. Direct questions were also asked, such as ‘does MSF do anything that may give the impression that they are not neutral, impartial or independent?’ and ‘what are the community’s biggest complaints about MSF’s presence?’. Limited access and the highly conservative nature of tribal society meant that MSF was unable to develop a full understanding of differences in opinion amongst different members of the community; in particular, MSF found it difficult to reach women, children and the very poor. Perception is seldom homogeneous within a community, and changes over time, so such monitoring should be done on an ongoing basis to determine whether original perceptions hold true.


The context

Any attempt to address perception and acceptance problems needs to include a thorough analysis and understanding of the political and historical context. Agencies also need to cast a critical eye over the humanitarian principles and laws that inform their work. This involves understanding how humanitarian organisations fit into a specific community’s worldview, and considering how local perceptions of humanitarian organisations feed into a global perception of humanitarian action, and vice-versa.

Within the context of the ‘Global War on Terror’, humanitarian organisations have increasingly been seen as an extension of Western political and strategic interests. This makes operating in contexts where there is opposition to Western military and political objectives very challenging. Western NGOs are often perceived as partial actors, inherently linked to the actions of Western governments. The Middle East tends to look to history to explain the present, particularly the history of Western colonialism and the Crusades. Additionally, conspiracy theories are common in Middle Eastern society, and are often used to confirm a particular worldview.

It is also important to understand how charity and humanitarian assistance are perceived in Islam, where charity is intricately tied to religion. Aid that is framed as part of a religious obligation does not provoke feelings of inferiority, but is seen as simply the fulfilment of a religious commitment. Secular charity, on the other hand, is much less understood, is viewed suspiciously and can often evoke feelings of humiliation or a loss of pride in the recipient. It is important to understand this when structuring programmes and communication messages surrounding aid delivery and humanitarian assistance. Tribal politics, though often ignored, are also important.

Finally, understanding the local context includes understanding the community’s experience with NGOs. In southern Yemen, NGOs have historically focused their projects on Somali and Ethiopian refugees at the expense of the local Yemeni population. Over time, a certain level of resentment towards these NGOs has developed, despite the fact that the community is generally sympathetic to the plight of the refugees. This resentment took the form of conspiracy theories about MSF’s presence in the community.



Perceptions of NGOs

Perceptions are important: whether right or wrong, they have real consequences for the acceptance of an organisation and its projects. In Abyan, MSF was perceived as an inherently Western NGO, and this perception brought with it a number of assumptions about the organisation and the aid it was delivering. Some within the local community asked whether there was any connection between MSF and Bulgarian nurses accused of infecting children with HIV in Libya – a conspiracy theory that has affected the perception of many foreign NGOs working in Muslim contexts. As locals became more familiar with MSF and the project, these suspicions subsided.

MSF cannot escape its roots as a Western organisation: it is embedded not just in the presence of expatriate staff but in the very way the organisation operates on the ground, the way it articulates its identity and principles and, in some cases, the way it radiates Western ‘superiority’. Often referred to as al-ajaneb (the foreigners), MSF expatriate staff were perceived to be respectful of the local culture, albeit unnecessarily threatened by it: national staff reported that some in the community felt that MSF staff were often ‘frightened’ by Yemeni tribal culture, partly due to a lack of awareness and contact with the community (given the security situation, teams were essentially confined to a small number of public areas).

Perception and acceptance works both ways: NGO perceptions of local culture also need to be critically reviewed and challenged. In Yemen, for example, there was a general assumption that having a female field coordinator would be problematic in a conservative, patriarchal society. In fact, expatriate and national staff did not notice a difference between having a male or female expatriate field coordinator. However, the female field coordinator was French rather than a national staff member, and foreign women are often seen in a different light than local women.


Perceptions of MSF principles

Assessing how an organisation’s principles are understood and perceived is an integral aspect of acceptance. What it means to be a humanitarian is understood differently in different contexts. In Yemen, problems arose with the local population over who was responsible for the burial of dead refugees. The perception was that MSF was not a humanitarian organisation, because the local imam had stipulated that to be a humanitarian meant respecting both the dead and the living, and caring equally for both. Solidarity also emerged as a key theme.

MSF’s concept of neutrality was perceived differently in the Yemeni context. National staff suggested that it would be difficult for the community to conceive of an organisation without political motivations, partly because of linguistic and conceptual differences in understandings of ‘neutrality’. Given the highly politicised nature of Arab society, political neutrality is generally not understood in the same way that Western humanitarian organisations articulate the concept. For example, neutrality was not possible in the Iraq war or the Israeli–Palestinian conflict, and individuals were generally assumed to have a political stance on most issues. Political neutrality in Yemen was thus more localised, and focused on MSF’s neutrality in tribal conflicts. In Yemen, emphasising ‘religious neutrality’, plurality and openness to all religions was seen to be more important than references to political neutrality.



A number of key points were highlighted to improve MSF’s acceptance. Initially, to address the problem of the community’s perception that international NGOs were focusing on providing assistance to refugees at the expense of the local population, MSF began to offer support to the local hospital. Delivering aid through mobile clinics, as was originally considered, was found to pose potential problems in terms of perceived impartiality and tribal neutrality, and it was decided that support to the existing hospital would negate the possibility that certain tribes might be overlooked.

MSF also adopted an approach to refugee assistance that focused less on the ‘rights’ of refugees and more on MSF’s – and the community’s – duty to help them. Similarly, framing assistance as solidarity with the refugees resulted in a more positive response from the community. In Yemen, this was not difficult given that the local tribes were helpful and accepting of the refugees. By sending messages of solidarity and thanking the local community, MSF was able to integrate its project with other forms of local assistance. This included working alongside fishermen and developing a network of local focal points to inform MSF of refugee arrivals.

It is important, however, not just to focus on common shared values but also to discuss differences: focusing on commonalities may serve to bring various groups to agreement, but often an honest discussion of differences may bring forth greater understanding. This thinking was applied to Yemen in the context of the complaints over the burial of dead bodies and what it means to be a ‘humanitarian’. Meetings were held with key authorities and the local imam in order to discuss these concepts, and through an honest discussion of these differences MSF was able to better understand the community’s perception of humanitarian action, and find a way to communicate its own perception.

A communication strategy was developed based on getting to know MSF as individuals rather than MSF as an organisation, enabling expatriate staff to explain who they were, their background and their reasons for working with MSF, hopefully allowing for a deeper understanding of the organisation beyond institutional discussions about principles and funding. Gaining the trust and acceptance of a foreign organisation in Yemen begins with gaining the trust of individuals working within the organisation.

Local perceptions also led to changes in the MSF project itself. For example, a better briefing was developed for international staff on tribal dynamics and Yemeni culture, and a national staff member was recruited to analyse issues such as context, perception and acceptance.



Humanitarian action needs to adapt to a changing landscape, and this requires being more culturally sensitive and politically savvy, more resourceful, more accountable and more creative in the way we put principles into action. An integral aspect of this involves working towards a more participatory, accountable, less intrusive and more self-aware form of humanitarian assistance. Following this study, sections within MSF have devoted resources to following up issues of perception and acceptance as an in-built measure to improve the delivery of aid. It is critically important that organisations engage with local communities on what their role should be and what the principles that they abide by stand for. Ongoing studies on perception are one way to keep humanitarian values alive and universal, and continuously challenged and refined, ultimately leading to better, more effective humanitarian provision to communities in distress.


Saleem Haddad is Programmes Researcher in the Programmes Unit, MSF-UK. His email address is



References and further reading

Feinstein International Center, Humanitarian Agenda 2015: Principles, Power and Perceptions, 2006,$file/Tufts-Sep2006.pdf?openelement.

Musab Hayatli, ‘Islam, International Law and the Protection of Refugees and IDPs’, Forced Migration Review, January 2009,

Saeid Rahaei, ‘The Rights of Refugee Women and Children in Islam’, Forced Migration Review, January 2009,

Hugo Slim, How We Look: Hostile Perceptions of Humanitarian Action, Centre for Humanitarian Dialogue, 2004,


[1] For more information, see ‘No Choice: Somali and Ethiopian Refugees, Asylum Seekers and Migrants Crossing the Gulf of Aden’, MSF, June 2008,


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