Author: MIL-OSI Publisher

Safeguarding and addressing issues around abuse is a top priority for MSF leadership. While increased attention and effort have been put into tackling these issues in the last two years, we recognise that we have further to go. Abuse and inappropriate behaviour have no place within MSF, and we are committed to keeping our patients, colleagues, and the communities in which we work safe.

Policies and strategic workstreams have been put in place which will enable safeguarding  to become a fully mainstreamed way of working, with its principles being integrated into daily practices and decision-making processes. All staff are expected to apply safeguarding principles in their work; safeguarding is being integrated into all roles at MSF, and is championed by all levels of leadership, who reinforce what behaviour is expected in MSF, and prioritise it in their planning processes and actions. Awareness raising and training sessions among staff on identifying, reporting, and preventing abuse continue and have become more widespread.  

MSF is continuing to collect data on behavioural complaints in MSF. A breakdown of the number and type of complaints we receive (made by staff, patients and their caretakers, community members, and others), and those complaints that are confirmed each year, can be found here. While each year generally sees incremental increases in the numbers of complaints received, as is anticipated with more available channels and raised awareness, we know that there is more work to be done to enable anyone affected by, who witnesses, or has concerns about abuse to have the confidence and trust report it.

MSF continues to work to create an environment free from abuse and harm for our staff and for patients, their caretakers, and the communities in which we work. A focus on prevention and detection of abuse, based on our commitment to zero-tolerance of inaction for abuse, alongside making reporting mechanisms adaptable, accessible and inclusive, are critical for this work. When reports about abuse are made, ensuring that there are sufficient, well-trained people in place to address them is also critical to illustrate our commitment to take allegations of abuse seriously. This includes to address allegations in a timely manner; take responsive and remedial action – including supporting survivors with any medical, psychological, and legal needs; and to sanction those found to have engaged in misconduct proportionally, should abuse be found to have occurred.

Over the last two years, we have moved forward in our efforts to prevent, detect, and address abuse by:

• Safeguarding vision and action plan – in 2024, the Full ExCom endorsed a safeguarding vision and action plan. This reflects a shared understanding that preventing and addressing abuse requires the participation of all at MSF.
• Pool of investigators – a pool of investigators was established, comprising external investigators (not MSF staff), with diverse professional backgrounds, specialisations, experience, nationalities, and languages, while testing a model for internal investigators.
• Ensuring safe recruitment to minimise risks to staff, patients and communities – we have put in place harmonised reference checks mechanisms within MSF to avoid hiring those who engaged in serious misconduct incompatible with MSF’s humanitarian work and behavioural commitments.  
• Typologies of abuse updated – the platform which oversees behaviour within MSF has reviewed and is updating the different typologies relating to abuse, including discrimination.

Many activities require ongoing and continuous work. For example, awareness-raising about expected behaviour and how and where to report about abuse, including for patients, caretakers and communities; briefing and training staff, integrating safeguarding throughout the employment cycle alongside diversity, equity, and inclusion (DEI) measures; safeguarding risk assessments; safe recruitment, whereby ensuring all new hires accept MSF safeguarding standards; strengthening efforts on DEI; focusing on patient centred approaches, including embedding safeguarding measures into healthcare delivery and other MSF programmes, projects, and services; case management and investigation; and understanding barriers to reporting.

Work is ongoing in other areas, including the development of a shared reporting platform to be used across MSF entities, as a supplement to other means of reporting. Operational Directorates are either in the process of transitioning behaviour units into safeguarding units or establishing dedicated safeguarding roles and clear structures to support safeguarding. More safeguarding positions, to assist and build capacity to integrate safeguarding in different roles in MSF’s country programmes, are being put in place. We’re also strengthening safeguarding practices related to the people we hire for daily labour, who are both vulnerable to abuse in precarious employment, and at risk of engaging in abuse. A safeguarding section in the Welcome to MSF package for new recruits has been developed and is being piloted.
 

In 2018, we listened to feedback from our staff that MSF’s salary and reward policies and processes did not align with our ambition for a diverse global workforce. Since then, we have been striving towards more equity and better transparency on how people are remunerated for their work. Through the Rewards Review which started in 2021, we carried out an in-depth analysis of our existing policies and process, and developed proposals on what needs to change. To address these inequities, over the last two years we’ve taken the following actions:

• A major review of our policies and processes – the Rewards Review – was carried out between 2021 and 2023 to systematically analyse MSF’s existing approach to pay and benefits. In October 2023 the Full ExCom approved an implementation roadmap, and in 2025, the Full ExCom agreed that the relevant teams had delivered a thorough review and formally closed the Rewards Review project, to then implement its recommendations.  
• New policies were designed and gradually rolled out on a living wage, and on paid leave.
• Rolled out more competitive pay for country-based coordination positions.
• Capped working hours at 48 hours/week.
• Defined a new a staff healthcare plan.
• Put in place a Global Pay Policy Framework that improves consistency and transparency on how pay is set.
• Completion of a global grading framework design and the mapping of existing jobs to align job grades and levels across MSF entities.

Implementation of specific deliverables, maintenance of the pay and benefits policies, and future adjustments in line with evolving needs continues as part of business-as-usual systems.
 

Working in contexts of violence and conflict have been an integral part of MSF’s operations since our inception. Ensuring the safety and security of our staff and patients is one of our biggest priorities, and challenges. We choose the areas where we run our projects, and in doing so, we seek to anticipate, prevent, and address security threats within projects.

Human resources restrictions for staff working in our programmes based on non-professional criteria – gender, ethnicity, physical appearance, religion, age, nationalities, etc – can be imposed on MSF by external organisations, such as states or armed groups, or decided by MSF. This is a compromise in our preferred way of working and we seek to limit the use of these restrictions to a minimum.  

When decided by MSF, the two rationales on HR restrictions are:  

• the safety and security of our teams and our operations; and 
• where required, to ensure our access to communities.  

An HR restrictions table, detailing the type and location of restrictions, was first compiled in early 2025 and shared across all ODs. The table maps all relevant information by country and is reviewed annually by the RIOD to ensure alignment and consistency of restrictions across similar contexts as much as possible.

In April 2025, the RIOD approved guidance on security information sharing and confidentiality in cases of violent sexual assault. The guidance provides a framework for ensuring necessary information is shared for incidents, including rape by external perpetrators, while protecting the identity and privacy of the persons involved.

Generally speaking, responsibility for safety and security measures for our staff lie principally with the ODs, with whom the bulk of this work rests. Therefore, the remit of the Core ExCom’s plan is to assist with the coordination of these measures.
 

MSF’s existing staffing model has led to unequal access to recruitment and career development opportunities. This contributes to a lack of diversity in team composition; poor gender ratios among programme staff; difficulties in access to coordination and management positions for locally hired staff; and has resulted in over-representation of staff of Western origin in the most senior and leadership roles.

MSF’s decentralised structure, with multiple legal employers and different approaches to recruitment and career management, poses significant challenges for recruiting and developing staff in line with movement-wide strategic priorities. Our current staffing model also does not enable sufficient medium- to long-term workforce planning. The Global Workforce Strategy, agreed by MSF’s leadership in 2025, addresses these issues through a more strategic, intentional approach to workforce planning and adaptations to HR set ups and services. This approach cultivates the diversity of MSF’s workforce and better harnesses it to deliver impactful medical humanitarian operations and ensure quality of care.

Our decentralised structure and various policies and practices represent a key challenge when it comes to recruiting, retaining and developing our staff. HR principles are applied differently across our various operational directorates and other MSF entities. As some operational directorates report a shortage of experienced international mobile staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff internationally and locally, and reversing the deteriorating gender ratios among mobile staff.  

The International Contracting Office (ICO) – which provides a consistent contracting experience, aligning pay and benefits for staff who don’t have an MSF contracting office in their own country – was established, and in October 2023 the ICO issued its first contracts to mobile staff. 
 

MSF communication and fundraising materials provide the public face of the organisation, therefore we must ensure that these materials respect and demonstrate the dignity and agency of patients and our staff, and to eliminate perceptions of white saviourism, neo-colonialism and racism. While work remains, significant progress has been made, with new tools, resources, and collaborative structures now in place to ensure diversity, equity, and inclusion (DEI) principles are increasingly integrated into daily communications and fundraising practices.

At the end of 2023, the Task Force on DEI in Communications and Fundraising concluded its work, having achieved its main goals:

• revising, simplifying, and mainstreaming the DEI Guide for Communications and Fundraising to ensure our teams create public communications that respectfully, ethically, and inclusively represent our staff, patients, and the communities we serve with dignity.
• contributing to the audiovisual (AV) ethics review, which assessed photos to identify any imagery that did not meet our ethical standards and DEI commitments. Based on the report’s recommendations, funding was secured for a dedicated position to develop, disseminate, and implement a new AV ethical framework for MSF, including expanding training, and promoting inclusive practices across operations.
• finalising MSF’s ethical storytelling guidelines.
   

To ensure continuity, the DirCom and DirFund, as well as the movement’s DEI Advisors, established a DEI Advisory Group with trained peer reviewers in early 2024 to sustain and expand this work. The group supports and trains teams, provides peer support and strategic guidance to international platforms, maintains training platform resources, convenes workshops and webinars, and drives DEI integration across communications and fundraising activities.

The group meets monthly, shares annual updates, and has its mandate reviewed and renewed regularly to ensure the structure remains fit for purpose.
 

MSF has made the commitment to systematically integrate DEI principles in deciding where and how we respond in the countries we work and in setting standards of care for the communities we work in. This commitment puts the focus on the people we serve, while ensuring our staff practice an inclusive and non-discriminatory provision of care.  

We are working to apply these principles to our existing medical policies, activities, and initiatives, based on three key pillars of work:

1. integrating diversity, equity and inclusion action points in medical guidelines and policies
2. implementing a patient/person/community-centred approach – focusing on the needs and wants of the patient as a person – and ensuring programme choices and project designs include a diversity, equity and inclusion lens, and
3. developing shared accountability through identification of relevant indicators and ensuring their application for proper monitoring and evaluation of progress.

Over the last two years, work on these areas have included:

• integration of economic, social and political factors in several learning and development modules.
• racism-related considerations and LGBTQI+ inclusions in health consultations building on pilot projects.
• revision of MSF research protocols with the Ethics Review Board.
• translation of medical guidelines, standard operating procedures, and frameworks into at least five languages, plus local languages when applicable. 
• In 2025, a significant review of the 2015 Mutual Accountability Framework – the tools and methodologies by which MSF measures the quality and relevance of our activities – was completed, which looked at the typology indicators used, the governance process, the quality of analysis, and to ensure that diversity, equity and inclusion are included in reflections. 
   

The history of MSF’s founding and evolution over the last 55 years has meant that the power and decision-making structure within MSF has been concentrated in Europe. In recent years, we have questioned how this decision-making power should be distributed across the MSF movement. Since the creation of the West and Central Africa Operational Directorate in 2019 – which granted decision-making on where and how MSF operations are run for the first time outside of Europe – this has slowly begun to change, and in 2025, another Operational Directorate, MSF Ubuntu, was approved. Decentralisation of some key roles and departments within European-based Operational Directorates has occurred outside of Europe. However, the decision-making entities in MSF continue, for the most part, to lie within Europe.

To address this, we’re critically evaluating and addressing our structure. This work allows us to maintain a solid and accountable system of governance, but provides more flexibility in having entities with decision-making power established outside of Europe.

Over the last two years, the following progress has been made:

• A new policy adopted in 2025 has removed barriers to becoming a section, such as the requirement for MSF sections to be financially self-sufficient and contribute revenue to the movement. This opens up possibilities for sections to be located in different parts of the world, and not only where fundraising income is viable. 
• The policy also reviewed who has the right to run operations in MSF and makes sure that sections, who are the link between the people who support us and the people we serve, share oversight responsibility of the implementation of what we do, or our social mission. 
• As a result of the new policy, a new operational directorate, MSF Ubuntu, was approved and established in 2025. It is jointly coordinated between MSF sections in Eastern Africa, Southern Africa, United Kingdom, and Spain.
• Some European entities are working on reducing their voting powers by merging into one entity, making space for other non-Europeans to join the decision-making table at the ExCom.
   

Addressing issues around abuse have been a high priority for MSF leadership. In the last two years, increased attention and effort have been put into tackling these issues. We continue to collect data on behavioural complaints in MSF. A breakdown of the number and type of complaints we receive (made by staff, patients and their caretakers, community members, and others), and those complaints that are confirmed each year), can be found here. While each year generally sees incremental increases in the numbers of complaints received, we know that there is more work to be done to enable anyone affected by, who witnesses, or has concerns about abuse to report it.

MSF continues to make efforts to create an environment free from abuse and harm for our staff and for patients, their caretakers, and the communities in which we work. A focus on prevention and detection of abuse, alongside making reporting mechanisms accessible and inclusive, are critical for this work. When complaints about abuse are made, ensuring that there are sufficient, well-trained persons in place to address them is also critical to illustrate our commitment to take allegations of abuse seriously, to address them in a timely manner, and take responsive and remedial action, should abuse be found to have occurred.
 
Over the last two years, we have moved forward in our efforts to prevent, detect, and address abuse by:

• Hiring a Safeguarding Coordinator – at the international level, an International Safeguarding Coordinator (ISC) was hired and started work in 2023. The ISC works to define and advance safeguarding work within MSF, working with all stakeholders across the movement. This includes defining what actions need to be taken by MSF to continuously improve our ability to prevent and detect abuse, enable reporting of abuse, ensure allegations of abuse are addressed, and ensure that there are trained people who can address allegations of abuse in a timely and professional manner. The ISC also coordinates platforms for behavioural leads in MSF (both in operations and partner sections).
• Working to create a pool of investigators – approving the establishment of a global pool of investigators for administrative investigations of allegations of abuse in the countries and projects where we operate or have presence.
• Common case management mechanism – a common case management mechanism has been designed to respond to concerns or reports of serious allegations of abuse spanning multiple MSF entities. The mechanism includes clear processes to be activated, to address such cases efficiently.  
• Field based positions – in Bangladesh and Afghanistan we’ve engaged staff to work on prevention, detection, strengthening reporting, and addressing abuse, as well as rolling out a safeguarding risk assessment in certain locations.

In addition, many activities require ongoing and continuous work. For example, awareness-raising about expected behaviour and how and where to raise complaints about abuse; training staff; training managers on how to welcome complainants; risk assessments; safe recruitment and performance management; strengthening efforts on DEI; focusing on patient centred approaches; case management and investigation; improving access to reporting mechanisms (including for patients and communities), and understanding barriers to reporting.

“We have listened to feedback from our staff, and we are striving towards more equity and better transparency on how people are remunerated for their work. Through the Rewards Review, we carried out an in-depth analysis of our existing policies and process, and developed proposals on what needs to change. This change is complex and ambitious, but we can’t afford not to succeed.”
– Dr Christos Christou, MSF International President

We are aware that MSF’s salary and reward policies and processes do not align with our ambition for a diverse global workforce. They do not adequately support our evolving operational and organisational requirements, lead to inconsistencies, hinder mobility, and are perceived as inequitable by many of our staff. To address these inequities, over the last two years we’ve taken the following actions:

• A review of our policies and processes – the Rewards Review – was carried out to systematically analyse MSF’s existing approach to pay and benefits. Between 2021 and 2023, this review involved over 4,000 staff, who provided input over 450 staff engagement sessions. The review also analysed data on how our workforce has evolved, how staff are paid today, and how MSF pays staff compared to other employers in similar contexts.  
• In April 2023 the results of the review were presented to the ExCom and identified problems, including: policies and practices that have not evolved with trends; unacceptable differences in pay and benefits packages; inconsistencies in valuing jobs and staff support; and inadequate HR governance and accountability.
• In May 2023, the executive leadership of MSF agreed to significant changes to MSF’s rewards policies to address these problems, including a set of core benefits for all staff; minimum standards for pay; a consistent definition of living wage with adjusted methodology; a consistent benchmarking approach; two new staff groupings – mobile staff and country-based staff – to replace the existing, outdated groups; and a framework to ensure that jobs and functions are graded consistently across the organisation.

These are very significant changes that will take several years to fully roll-out. However, key improvements for some staff have already been implemented from October 2023 including:

• The removal of the indemnity (the practice whereby mobile staff received an indemnity payment instead of a salary for the first 12 months of working with MSF).
• The launch of the International Contracting Office (ICO) to provide a consistent contracting experience, aligning pay and benefits for staff who don’t have an MSF contracting office in their own country (see more under section 4, People recruitment and development).
• The set up of the MSF International Retirement Savings Plan for ICO contracted staff.

Working in contexts of violence and conflict have been an integral part of MSF’s operations since our inception. Ensuring the safety and security of our staff is one of our biggest priorities, and challenges. We choose the areas where we run our projects, and in doing so, we seek to anticipate, prevent, and address security threats within projects.

Human resources restrictions for staff working in our programmes based on non-professional criteria – gender, ethnicity, physical appearance, religion, age, nationalities, etc – can be imposed on MSF by external organisations, such as states or armed groups, or decided by MSF. This is a compromise in our preferred way of working and we seek to limit the use of these restrictions to a minimum.  
 
When decided by MSF, the two rationales on HR restrictions are:  

• the safety and security of our teams and our operations; and
• where required, to ensure our access to communities.  

HR restrictions processes, decision making, and implementation are internal to each OD, but the processes are shared amongst ODs. Furthermore, the type and location of restrictions are also shared and reviewed once a year at the RIOD; each OD is responsible to update this common tool.

Generally speaking, responsibility for safety and security measures for our staff lie principally with the ODs, with whom the bulk of this work rests. Therefore, the remit of the Core ExCom’s plan is to assist with the coordination of these measures.

MSF’s existing staffing model has led to unequal access to recruitment and career development opportunities. This contributes to a lack of diversity in team composition; poor gender ratios among programme staff; difficulties in access to coordination and management positions for locally hired staff; and has resulted in over-representation of staff of Western origin in senior and leadership roles.

Our decentralised organisational structure, with multiple legal employers and different HR policies and practices, represents a key challenge when it comes to recruiting, retaining and developing our staff. There is no single organisational workforce strategy, and our principles are applied differently across our various operational directorates and other MSF entities. With a number of our operational directorates reporting a shortage of experienced international mobile staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff internationally and locally, and reversing the deteriorating gender ratios among mobile staff.  

To address these and other inequities, over the last two years, we have achieved the following objectives:

• Contracts for staff located without an MSF office – an International Contracting Office (ICO) was established, and in October 2023 the ICO issued its first contracts to mobile staff who don’t have an MSF contracting office in their own country and ran the first payroll. The ICO provides a consistent contracting experience, aligning pay and benefits for these staff regardless of the operational directorate they work for. It also provides a seamless support during their career with MSF and one single point of contact for contracting purposes.
• Delocalised headquarters – the International Office and a number of the ODs have increasingly delocalised positions, and even entire departments, away from their traditional European bases. This means that vacancies for headquarters positions are being opened across regional hubs, including in Nairobi, Amman, Dakar, Dubai, Bogotá and Buenos Aires, increasing diversity in some of those positions and departments and HQs in general.
• Job vacancies page – a recruitment page on msf.org was launched, so that job vacancies across many MSF offices are accessible to anyone interested in working for MSF; 1,685 vacancies were published since the site’s launch in April 2022 until the end of 2023.
• Accessible employer policies site – a new site (rewards.msf.org) with information on ‘MSF as an employer’ and reward policies was launched in 2022, accessible to all MSF staff (including those without an MSF email address and therefore no access to the organisation’s intranet).
• Human resources portal – a human resources portal was launched, and all HR policies and guidelines were made accessible in Arabic, English, French and Spanish to staff with access to an MSF computer; for staff without an MSF log in, we have made policies available on the rewards page on msf.org.
• Improved data reporting and analysis – the 2022 MSF Staff Data and Trends Report, published in June 2023, included improved analysis and more detailed reporting on workforce make-up, to help us improve our understanding of our workforce and how it’s evolving. ODs are using this information to inform approaches to recruitment and development through the Recruitment and Career Management Platform.

“We are committed to respecting the dignity and agency of the people we treat, and recognise that this is fundamental to fulfilling our mission to bear witness and speak out about human suffering. We are working to improve our guidelines, standards, and policies, and we are also shifting our own mindset.”
– Dr Christos Christou, MSF International President

With MSF communication and fundraising materials providing the public face of the organisation, calls to ensure that these materials respect and demonstrate the dignity and agency of patients and our staff, and to eliminate perceptions of white saviourism, neo-colonialism and racism, have become urgent from both within and outside of MSF. While there is still work to do, there has been significant progress made towards achieving the objectives set for Communications and Fundraising in tackling Diversity, Equity and Inclusion (DEI) issues. They include:

• DEI guide for communications – a DEI guide was produced by the dedicated taskforce that advises MSF teams on the creation of more respectful, ethical and inclusive public communications productions that accurately represent our staff, patients and the communities with whom we work in a dignified way. A course on using the DEI Guideline has been developed in English, French and Spanish and has been published on our inhouse training platform.
• DEI language guidelines – starting in mid-2021 and continuing into 2022, “Guidelines to equitable, respectful and inclusive language in MSF communications” were published in languages including English, French, Arabic, and Spanish. These guidelines, which complement the DEI guide, help MSF content producers, editors and disseminators use appropriate terms to describe people, crises and contexts. Other, topic-specific guidelines – such as on disability – were produced and disseminated in 2022 and 2023.
• DEI-focused positions – a temporary DEI Guideline Roll-out Coordinator position was recruited at the end of 2022 to facilitate the rollout and training on the guide, with a fundraising professional also trained as a DEI facilitator identified. This role has since ended given the roll-out had been completed as envisaged.
• Online DEI hub – the DEI knowledge hub for MSF Communications and Fundraising Professionals, also known as Ubuntu, was also launched in September 2022. The aim of this online internal hub is to inform and inspire communications and fundraising teams on DEI matters and link to existing internal and external resources on the topic.
• Feedback group – a Peer Feedback Group was created to provide feedback on the sensitivity of packages, with a large group of volunteers from across the movement reviewing communications content and flagging concerns related to portraying patients/communities in an undignified manner, advancing stereotypes, and/or the inclusion of hero/white saviour narratives. The Peer Feedback Group’s highly valuable work has since been promoted further to ensure support is sought early in e.g. campaign production development processes.
• Media database review – An audio-visual media database content review was launched in 2021, with a revision of photos being completed in August 2023. More than 150,000 pictures were reviewed to identify any imagery that did not comply with our ethical standards and DEI commitments, with 114,000 being reviewed twice; about 12,500 photos were flagged and 2,500 have since been removed from view and use.
• Pledge to tackle problematic imagery – in June 2022, the Full DirCom issued a statement pledging to accelerate action on multiple fronts to better manage the collection, use, dissemination, and storage of photographs and video taken at our medical projects.
• External advice and recommendations – Following the Full DirCom’s pledge, and based on the work of the database review, a series of workshops with two advisory panels – one with medical and other functional experts from inside MSF and another with academics and professionals from outside MSF – were organised to gather their advice and recommendations on audio-visual practices, with a report being produced.
• Audio-visual ethical framework – from the report’s recommendations, funding was secured for a position to develop, disseminate and roll-out (including through appropriate training) a new audio-visual ethical framework (guidelines) for MSF. This expert was identified and started work in January 2024.
• Photographer contracts proposal – After being alerted that images that do not comply with our DEI commitments taken previously in MSF structures remain available for distribution by photographers or through photo agencies, contracts for photographers have been collected and reviewed, and proposals for new clauses and contracts have been produced.

MSF has made the commitment to systematically integrate diversity, equity and inclusion principles in deciding where and how we respond in the countries we work and in setting standards of care for the communities we work in. This commitment puts the focus on the people we serve, while ensuring our staff practice an inclusive and non-discriminatory provision of care.  

We are working to apply these principles to our existing medical policies, activities, and initiatives, based on three key pillars of work:

• integrating diversity, equity and inclusion action points in medical guidelines and policies
• implementing a patient/person/community-centred approach and ensuring programme choices and project designs include a diversity, equity and inclusion lens, and
• developing shared accountability through identification of relevant indicators and ensuring their application for proper monitoring and evaluation of progress.

Over the last two years, work on this area has included:

• Patient Charter – In 2023, a patient charter was developed in consultation with internal and external experts as well as patient representatives, and finalised in collaboration with the International Board. Based on the provision of effective, safe, and equitable healthcare in the contexts in which we work, the Charter’s principles include Dignity and Respect; Safe healthcare and Protection; Access; Information; Participation and Consent; Privacy and Confidentiality; Feedback and Complaints Procedures. These principles today serve as a guide for each operational directorate to implement and adapt according to the cultural and context particularities of their project settings.
• Protecting patient data – Work on implementing a patient data protection strategy has continued, which ensures the protection of patient health data centred on patient rights and medical confidentiality. Critical in ensuring protection is in informing patients on how their medical information is used and what mechanisms are available to them in case of concern.  As part of this effort, a patient health information notice form has been finalised and is being systematically included in our facilities.
• A list of quality-of-care indicators – A library of quality-of-care indicators was developed and approved by the DirMed and MedOp platforms, to be used by the various intersectional medical platforms and ODs in their data collection sets. This should help in the monitoring of the levels of quality of care achieved in a given time period. In addition, patient safety indicators are also being standardised.
• Coherent optimisation of activity data – A health data strategy has been developed under the DirMed platform that aims to optimise and secure the use of medical activity data (number of consultations, type, etc), providing a coherent approach across ODs. The strategy takes a data minimisation approach, which helps ensure quality monitoring, that unnecessary data is not collected, and that patient information is used optimally.  
• Quality medical products review – In ensuring we are providing quality medical and healthcare products, a review of the work of the Quality Assurance team was undertaken, with areas of progress and further need for development highlighted. Work on this is coordinated between the International Medical Quality Products and Publication team, supply centres and the Global Procurement Unit, amongst others.
• Mutual Accountability Revision process – a revision process of the mutual accountability mechanism – the tools and methodologies by which MSF measures the quality and relevance of our activities – was launched in 2022, to review the typology indicators used, the governance process, the quality of analysis, and to ensure that diversity, equity and inclusion is included in reflections. An important part of this revision is finding with which teams and stakeholders need to be engaged and consulted to capture relevant information, data and reporting.  

The history of MSF’s founding and evolution over the last 50 years has meant that the power and decision-making structure within MSF has been concentrated in Europe. In recent years, we have questioned how this decision-making power should be distributed across the MSF movement. Since the creation of the West and Central Africa operational directorate in 2019 – which granted decision-making on where and how MSF operations are run for the first time outside of Europe – this has slowly begun to change. However, the decision-making entities in MSF continue, for the most part, to lie within Europe.

To address this, we’re critically evaluating and addressing our structure. We’re doing this through a project which will allow us to maintain a solid and accountable system of governance, but which would provide more flexibility in having decision-making entities established outside of Europe.

Up until the end of 2023, the Full ExCom developed a vision document on how to manage the number and location of current and future entities, always keeping how these entities will benefit the work of MSF at the core of their decisions.

There is clearly an unacceptable gap between what we should be doing and what we are doing – for our own staff and for our patients and their communities.

Complaints from MSF staff and association members, as well as public reports, have indicated that there is insufficient trust in both reporting mechanisms and the management of complaints within MSF. Part of the answer to this lack of trust is the need to increase the ownership of these mechanisms at all levels of the organisation, by providing dedicated trained staff and financial resources, and by encouraging our diversity, equity and inclusion (DEI) and behaviour units to learn from each other’s expertise.

Our internal reviews have also shown that MSF struggles to respond rapidly enough to cases of abuse and inappropriate behaviour in the countries and emergency contexts in which we work. In 2020, we received 389 reports of abuse, including 41 complaints of discrimination. 

To begin to address these shortfalls, we have created the following initiatives: 

• A platform to share best practices and develop tools for managing cases of abuse, including developing clear and systematic messages on acceptable behaviour.
• A shared anti-discrimination learning programme, which can be adapted to local needs and will be suitable for all staff, both in our projects and in headquarters.  
• An induction module on behaviour, as part of the general induction available to all new staff.
• An ‘Anti-Racism Project’, which aims to create anti-racism awareness and embed anti-racism practices into the way we operate.
• An intersectional booklet on behaviour which provides an overview of how we deal with behaviour issues.
• A range of other tools including posters, videos, briefing packages, trainings, workshops and case management guidelines. 

At the same time, we need to ensure that our patients and the communities with whom we work are included in the prevention and detection strategies we are developing. So far, this has been a challenge, given the slow progress made on adapting messages and tools for each country. We are aware that we have not yet made sufficient efforts to communicate proactively with patients and communities regarding their rights and their options to bring grievances to MSF We also aim to decentralise prevention, detection, case management towards regional and local levels.

“In conversations with MSF staff members from across the globe, we are challenged frequently on rewards policies and on the different treatment experienced by different staff groups. People are right to challenge us – and to challenge MSF leadership – because we have much more to deliver.” – Dr Christos Christou, MSF International President.

We are aware that MSF’s reward policies and processes do not align with our ambition for a diverse global workforce, are insufficient to fully support our evolving operational and organisational needs, lead to inconsistencies, hamper mobility and are perceived as inequitable by many of our staff. Specifically: 

• There is a lack of clarity about the principles guiding our rewards and how they are applied or prioritised.  
• Historic staff groupings (ie ‘international staff’, ‘national staff’ and ‘headquarters staff’) are outdated.
• MSF offices use different salary scales to determine pay and benefits, which leads to inconsistencies and hinders joint operational initiatives and staff mobility. In some contexts, salaries at the lower end of the scale are not sufficient to guarantee a decent standard of living.
• The current remuneration system for internationally mobile staff is seen by some staff as inequitable and discriminatory because it uses domicile as a basis for determining pay.

To address these inequities, we have set up the ‘Rewards Review Project’ and will launch the ‘MSF International Contracting Office’ (see section 4 for more details – LINK), which include the following initiatives: 

• Our ‘Contracting and Rewards Strategy’ will define how we group staff to determine where and how they are contracted and rewarded. This will specify whether a staff member is paid a local salary, a global salary or a combination of the two, and will specify the rewards staff may receive in addition to their salary and core benefits. To design this strategy, we are receiving expert technical advice and comparing our system with that of other international NGOs.  
• Our ‘Minimum Standards for Pay and Benefits’ will specify how local and global salary grids are developed, how they are benchmarked against labour markets, how they take into account the cost of living, and how they are adjusted and reviewed. We are also building a comprehensive database of MSF benchmarking data. Initial proposals for minimum standards for benefits include parental leave (for birth or adoption), paid leave and death and disability benefits.
• Our ‘Global Grading Framework’ is being designed with the help of external management consultants to ensure that positions are graded consistently, regardless of where the job is located.
• The complex requirement for our rewards, the size and diversity of our workforce and our organisational structure means that the Rewards Review deliverables require time and investment. In addition, the impact on our workforce and wage bill will be significant. We expect design and stakeholder engagement to continue through 2022, with implementation starting at the end of 2022. 

“In some insecure contexts, the presence of certain profiles can increase the risk of detention, abduction and armed attacks, both for individuals and MSF teams as a whole. We know that there is a need to improve our overall understanding of exposure to risk and impact, including in highly insecure contexts and in relation to types of operations and categories of staff.” – Dr Christos Christou, MSF International President.

This will involve developing consistent guidelines about which conditions justify selecting staff according to their non-professional profiles – a practice known as ‘profiling’, which consists of selecting people according to criteria such as ethnicity, nationality, gender and religion. 

To address this issue, we held a workshop in Dakar in October 2020 to analyse the main issues around profiling and discuss the ethical questions it raises. These include: to what extent is it acceptable to practice this de facto discrimination? To what extent does profiling increase the security of individuals, teams and MSF as a whole? What are the consequences of profiling on staff members’ career paths and on our human resources policy? Further discussions in September 2021 concluded that profiling should be used solely for security management with the aim of mitigating risks for MSF staff and operations.

MSF is currently involved in a major two-year internal consultation process to define its medium-term vision; one of the areas explored is acceptance of risk. The issue of risk differential per categories of staff will be part of that conversation. 

MSF’s existing staffing model has led to unequal access to recruitment and career development opportunities. This has caused a lack of diversity in team composition, created gender disparities in some staff groups, restricted access to coordination positions for locally hired staff, and resulted in over-representation of staff of European and Western origin in senior headquarters leadership roles. 

Our decentralised organisational structure, with multiple legal employers and different HR policies and practices, represents a key challenge when it comes to recruiting and developing our staff. There is no single organisational workforce strategy and our principles are applied differently across our various operational centres and other MSF entities. With several of our operational centres reporting a shortage of experienced internationally mobile staff, a further challenge is how to retain experienced staff at the same time as recruiting and developing new staff.  

Despite these challenges, there has been progress in the right direction. Our Dakar office is now the third largest recruiter in the MSF movement, after Paris and Brussels. We are certain that finding qualified staff from a broader range of regions will contribute to a better mix in our field teams and change the profile of our leaders and decision-makers in the medium and long term. 

Data shows that our internationally mobile workforce has become more diverse over the past 10 years. In 2020, 50% of 3,326 full-time equivalents (FTEs) were from countries in the Global South – a two-fold increase on 2009. 
However, internationally mobile staff from the Global North are more likely to be in senior management positions (including heads of mission), while those from the Global South are more likely to be in other roles. We need to look further at the reasons behind this.
The data also draws attention to other structural weaknesses – for example, only 33% of our project staff are female, and the percentage of our internationally mobile staff who are women recently fell for two consecutive years, from 46.2% in 2018 to 43% in 2020; again, we need to understand the reasons behind this. 

To address these and other inequities, we have put in place the following initiatives:

• The ‘MSF International Contracting Office’ aims to address persisting inequities and administrative problems encountered by the 50% of internationally mobile staff who are resident in a country where MSF does not have a contracting office. Currently, these staff receive their contract from the operational centre which manages their assignment, which means they have no contract consistency if they are hired by another operational centre, hampering their mobility and access to jobs and causing differences in pay and benefits. From mid-2022, these staff will be provided with consistent contracts and better pay and benefits throughout their employment with MSF.
• Our learning and development platform, ‘Tembo’, aims to transform the way that our staff work, learn and develop themselves in order to maximise their skills, their talents and their positive impact on our humanitarian work.
• Our diversity, equity and inclusion repository and knowledge-sharing platform will facilitate a common understanding of DEI issues by developing a framework of accountability across MSF and facilitate a fluent exchange of information, insights, experiences and best practices between DEI practitioners in headquarters and in our projects. 

We are also improving access to human resources information so that all staff can inform themselves about the policies and the rationale behind them, with the following initiatives:

• A new recruitment page on msf.org will mean that all vacancies will be accessible to anyone interested in working for MSF. To be launched in early 2022.
• A new site (rewards.msf.org) with information on ‘MSF as an employer’ and reward policies will be accessible to all MSF staff (including those who have no MSF email address). To be launched in mid-2022.
• A new HR Portal with all policies and guidelines will be accessible to staff with access to an MSF computer. To be launched in early 2022.

For many years, people working in communications and fundraising across MSF have had animated discussions on how to represent our work, our staff, our patients and their communities in a way acceptable to everyone. There have been regular challenges from within and outside MSF about materials perceived as insensitive, culturally inappropriate, failing to display the true diversity of our staff, or failing to show the agency of patients and members of their communities. In worst-case scenarios, some materials have been perceived as reinforcing white saviourism, neo-colonialism and racism.  

We fully intend to address these issues, while being aware that the concept of sensitive communication or representation varies from one society to the next and between languages. We need to find the right balance and refrain from imposing a single norm across MSF. At the same time, we need to ensure that our communications and fundraising staff can continue to release hard-hitting and truthful accounts of suffering and disaster when producing communication tools and campaigns, while seeking to do so in ways that avoid stereotyping and labelling individuals or communities in ways that could be offensive or could contribute to colonial, racist or other discriminatory tropes.

We have launched the following initiatives to make sure that our public communications embrace the principles of diversity, equity and inclusion: 

• A dedicated taskforce was set up in April 2021 to work on the application of DEI principles to all of our communications and fundraising strategies, products and materials, including aspects related to racism and racial discrimination, as well as to gender, LGTBQIA+, people with disabilities and other forms of discrimination. It will adapt existing guidelines, produce a new guidance document, and organise and systematise the sharing of knowledge and experience around DEI to promote good practice. Once the guidelines are finalised in early 2022, we will use them as the basis for training and induction materials.
• An internal ’sounding board’ group will be active from January 2022 to look at upcoming communications products and campaigns from a DEI perspective.
• An online portal on DEI, available to all communications and fundraising staff, will be launched in early 2022.
• A project has been set up to review the 180,000 photos and videos hosted in our audio-visual media database, some of which date back 50 years. We will make sure that they comply with privacy and copyright regulations and we will critically review, annotate, archive or remove items which are outdated, sensitive or detrimental to a positive representation of our staff, communities, patients and activities. 

Against a backdrop of growing attention to discrimination, racism and accountability, we are developing processes to begin the integration of DEI into our medical policies and activities. At the same time we aim to reform medical data and activities to ensure that not only can we provide a quality service, but we can also hold ourselves to account for our choices and actions.

In early 2021, our medical directors began implementing the ‘Improving Collaborative Leadership’ (ICL) initiative, which aims to review interactions on medical issues within the MSF movement. DEI will also be integrated into our consultation processes with patients. 

In recent years, we have begun to question how decision-making power should be distributed across the MSF movement and shared with our projects for the benefit of our future social mission. As part of this, we have set up the ‘MSF Structures Project’, which aims to clarify ways in which new voices can become central to our collective decision-making process, while maintaining a solid and accountable governance mechanism. We plan to remove barriers, such as the requirement for MSF sections to be able to financially support themselves and contribute revenue to the movement.

This project will allow for more flexibility around the creation of new entities and will allow for alternative and innovative approaches which do not fit into the current rigid structure. 

Already, representation at the highest levels of the MSF movement is shifting: in 2020 and 2021, three new non-European regional sections (MSF Latin America, MSF South Asia and MSF East Africa) became voting members of MSF’s highest executive platform, bringing new voices to our governance structure, while MSF West Africa obtained the right to run operations.