From Patients to Paperwork: The Tale of MSF's Institutional

Direction

Following the various operational reviews and institutional discussions that have taken place in
recent months across the movement, we, operations managers in the movement, are questioning
the path the MSF movement is following as well as its priorities.

Considering recent operational reviews and institutional discussions within the MSF movement, we,
operations, are concerned about the direction and priorities taken by the MSF movement.

Significant budget cuts have been imposed on operations for the 2023 financial year, which have
forced us to abandon new initiatives, close projects, lay off staff and hence to reduce the number of
patients treated. These restrictions are repeated in 2024 and 2025, which pushes us even more to
scale down our activities in countries in crisis.

We understand that these restrictions are partially necessary because growth cannot be unlimited.
We understand that these cuts are more a stabilization phase in our growth than an actual reduction
but when it comes to operations, they translate into closing and downsizing services for patients.
Moreover, these cuts are sometimes difficult to understand and accept given MSF's ever-expanding
institutional footprint.

There is a multitude of institutional initiatives and projects not supported by operations: while some
are interesting and legitimate for the evolution of MSF, others, on the other hand, appear to us to be
outside the realities of the fields, and far from the needs faced by our teams and our patients. The
people running these initiatives seem to be even unaware of the significant impact they may have on
the conduct of our operations. And in general, we wonder about the capacity of our movement to
absorb all the brilliant ideas that are added and added, with extra accountability required.
Does the reflection on stabilization of growth include all the movement, all the institutional
initiatives?

It is obvious that Operations do not have the exclusive right to carry out initiatives and that the
strength of MSF lies in its associative identity, but the gap is widening. The operational/non-
operational disconnection seems to us to be increasing in the movement, but also within a same
section. Big efforts are requested from Operations, and we expect equal effort to be requested to
every entity within the movement. Efforts should be made on mutualization, rationalization of our
operation but the same concern and efforts should be made at all levels.

It is not a question of opposing or quantifying Operational, Institutional, Associative, but we fear

more and more a loss of centrality of medical and humanitarian operations in MSF due to initiatives
qualified as " useful to the social mission" but which unfortunately are far from it. Yet it is Operations
that give MSF its strength, legitimacy, and credibility in the field and in the public arena.

We are raising the alarm about the risk of loss of operational space in the movement, about the
concrete challenges that our operations are facing because of our own internal ways of functioning,
and about seeing a loss of sense of reality in the exchanges which are often opposed, and which
leave less and less room for nuances.

Several reference documents have been published and documented on what is called the
“MSFWWTB”, particularly in the HR domain (valuation of employees, investment in medical profiles,
work culture, discrimination, etc.) but also public positioning, transparency and “accountability”,
structure, size bureaucracy and growth of the movement, etc.
So many topics that seem relevant to operations but lead us to wonder:
• How are resources allocated and on which projects in priority?
• What is the place of Operations in all the subjects covered by these projects?
The same can be said for other initiatives and projects – which seem to be governed more by political
intentions than by operational ambitions.

While part of our budgetary growth is mechanical (inflation, exchange rate, wages, etc.), another is
due to our own institutional choices. And it’s adding more burden and confusion on field teams,
asking them to support and implement all these different initiatives with lack of priority and visibility
on all these directions are going to.

The level of mutual accountability required between sections, including the international office,
appears questionable and not always in line with the needs of patients.

It seems to us more and more that institutional intentions and ambitions appear confused,
uncontrolled, and unfortunately may take priority over operational intentions.

The term “operational support” has become a generic label that enable anyone to obtain funds,
human resources and a place around the decision-making table, despite the fact they don’t align with
missions’ original needs. When faced with difficult budgetary choices that lead to downsizing or
closing operational projects we must challenge the relevance of that support and ensure it fits with
the institution’s current implementation capacity.

We strongly believe that operational priorities for the benefit of medicine, care, patients and staff
must be taken into account at all levels, which means:
- Investments in HR policies, equal opportunities, gender balance, salary policies, health
coverage, abuse prevention, recruitment...
- Supporting the emergence of new operational entities based on the same values that have
built MSF throughout its history, and not only regional offices of representations,
bureaucratic non-entities that consume resources and energy to create their own work and
manage intersection or “operational support” through non-operational people.
- Medical innovation, pharmaceutical quality, humanitarian, and humanistic medicine must
remain the primary objective of any new initiative.
- Build operational, optimal, efficient, decentralized supply chains with adequate tools.
- Revitalize our public speaking, make them stronger, more committed, and less diluted or
politicized. Keep the MSF voice unique and precious.

There needs to be a wider debate at the highest levels about responsibility, and priorities of the MSF
movement with real strategic choices and institutional decisions that keeps Operations at the heart
of our preoccupations.
The elected MSF International Board plays a crucial role in ensuring that MSF can fulfill its mission of
providing medical care in crisis situations while upholding its fundamental principles. It holds a key
position when it comes to governance, decision making, financial oversight, accountability and
representation.
We request that the IB takes its full role and holds responsible all MSF entities for their strategies,
growth, actions and decisions that impact the social mission, and make sure mitigation measures are
in place to ensure that, as a worldwide Movement, we maintain the focus on the reasons why MSF
was created.
All RC in OCP
Emanuel Lamper, OCB
Corinne Benazech, OCA
Mariano Lugli, OCG
Stefania Giandonato, OCG
Silvia della Tommasina, Cammino
Vittorio OPPIZZI, OCG
Sylvain PERRON, OCG
Francesca QUINTO, OCG desk Amman
Emmanuel Massart, OCB deputy desk
Shahbaz Israr Khan, OCB
Paul Brockmann, OCA
Julien RAICKMAN, OCB
Francesca Quinto, OCG
Martine Flokstra, OCA
Bakry Abubakr, OCbA
Aissami Abdou, OCB
Moussa Ousman, OCG
Djoen Besselink, OCA
Gisa Kohler OCBa and all the cell 3 (Maria Simon Deputy Reco, Liliana Palacios Health Advisor, Laura
Nicolai HR, Sergio Ferrer Cervero Finoco, Lali Cambra Communication Advisor)
Julien Buha Collette OCB RST8 – Europe / Operational team leader
Federica Zamatto OCB RST8 – Europe / Medical team leader
Come Niyongabo, RC OCBA
Livia Tampellini, Deputy Desk, OCB
Himedan Mohammed, OCBA
Celia Roman, OCBa Health Advisor
Sandra Lamarque, OCB
Filipe Ribeiro, Country Representative Afghanistan
Ximena Campos Moreno, OCB