Management at Médecins Sans Frontières

We thank Marion Péchayre, Director of Studies at MSF CRASH, and Elba Rahmouni for allowing us to republish this article for our readers. Marion Péchayre is an anthropologist of humanitarian action with a long experience in the field. We must salute this reflection on management, which in fact concerns all humanitarian organizations, which will no doubt find it a source of inspiration.

In this interview, various problems relating to management at Médecins Sans Frontières are discussed with Marion Péchayre, Director of Studies at CRASH, such as the fragmentation of work, the drift of professionalisation towards a position of control embodied by the multiplication of management tools and the omnipresence of requests for validation, or the disappearance of the role of individuals in favour of a pseudo-scientific presentation of facts and projects.

Elba Rahmouni: In recent years, in operational and institutional discussions, certain difficulties have been described as management problems. The meaning of the word “management” is often taken for granted, even though it covers different notions. At Médecins Sans Frontières, we use it to refer to different realities, whether it concerns our working methods, project management, human resources management or structural organisational issues. Why and how did you tackle this management issue?

Without a political reflection on work, the tendency of any organization is to promote conventional management practices, those that have prevailed in the world we live in since the beginning of the 20th century and which, as a result, appear to be neutral. The cardinal value of conventional management is performance, both collective and individual: it defines performance in relation to the achievement of objectives, which are themselves evaluated by means of indicators, most of the time quantitative. In this logic, work is supposed to be predictable because it is reduced to processes, associated with deadlines, and must comply with quality standards defined within each department. It is this “scientific organisation of work”, originally thought up for industrial mass production, that established the rules for the division of labour so that each worker specialises and contributes to the production of a standardised product. In this logic, the total quality of the finished product is considered to be the sum of the quality of each worker’s work.

Throughout its history, MSF has been no exception and has adopted, if not all the practices of conventional management, at least its theoretical framework. Historically, therefore, work has gradually been organised by department, each specialised in a field of action: logistics, finance, human resources, etc. The same logic continued in the form of external growth with the creation of satellites such as MSF Logistique and Epicentre in 1987. As Rony Brauman pointed out during a workshop on medical quality organised by CRASH in 2016, this structuring took place in reaction to a form of amateurism and with a desire to improve the level of care for patients by standardising medical practices to a minimum. It is largely thanks to this that MSF has become an organisation capable of caring for millions of people around the world. This specialisation has also helped to improve the quality of medical care in the field1. However, for some time now we have undoubtedly been caught up in the growth with this tendency to increasingly divide the work into sub-specialties, including within each department.

Today, this excessive division of labour hinders us on a daily basis. Tensions between departments, both at headquarters and in the field, are legion because vertical communication within a function takes up more space than between members of the same project team. This fragmentation of work makes it difficult for all of us to see clearly in the structure, to understand who does what: in the field we often wonder who to contact for a certain question, or who is responsible for a certain decision to be taken. At headquarters, we complain that we receive far too many requests for validation, and in the field, we are not sufficiently consulted or involved in certain decisions. Our procedures allow us to manage large volumes (of recruitment purchases), and this is essential; however, we seem to have difficulty in doing so when the need is unusual – for example, for the recruitment of plastic surgeons, gynaecologic oncologists.

We imported not only the idea of organizing work by specialty, but also the idea that total quality would be the sum of the qualities of each specialty and the associated assumption that human error is the main source of the problems encountered in project implementation. According to conventional management, the “human factor” should be minimized by setting up procedures and standards. However, if we reflect on the nature of our work at MSF, which is the production of medical and humanitarian operations, it seems to me that it is characterised in particular by a high degree of uncertainty, which requires the intervention of people to adapt procedures and other guidelines to each situation. In our work, decision-making is often a gamble that relies on the experience of individuals and their ability to deliberate, at least as much as on their knowledge of standards, guidelines or medical science.

The current structure is the result of a series of reorganizations, the creation of new positions or new departments, the most recent of which (such as the move to a cell) have already attempted to address issues such as “working in silos”. My intuition is that today we should rather try to work with the organization as it is, asking ourselves how we can change the way we work with each other to compensate for the trends induced by the structure. This may then lead us to reform the structure.

Elba Rahmouni: In La Revue Critique Borno, the authors, Judith Soussan and Fabrice Weissman, explain that the management tools used by the teams at headquarters and in the field (project sheets, reviews, visit reports, sitreps …) have not been able to clarify and arbitrate several controversies. They show that headquarters (or the country coordination level) behaves as a controlling rather than a supporting body and that the field tends to be self-censoring. What can you tell us about the management tools at MSF and how decisions are made? 

I would say that we have both too many and not enough management tools. Too many tools coming from the support departments, which add up for the field teams, and a weakness in the transversal tools available to coordinators to monitor projects.

There is therefore a certain accumulation of reporting requirements, mainly from the support departments, which sometimes creates the feeling in the field of being overwhelmed by MSF bureaucracy, of having to spend more time in front of one’s computer than with patients or external interlocutors. On the other hand, project coordinators complain about the lack of cross-cutting tools or processes to facilitate the monitoring and steering of projects. Some explain, for example, how confusing it can be when taking up a new position to be unable to refer to a clear and institutionalized project management framework. Project coordinators complain chronically that the objectives of some projects are not clear, or change without understanding why. Some add that they have no control over such changes.

It can be hypothesized that this combination of an overload of tools from the support functions (aimed at accountability and control) and a lack of tools supporting cross-cutting functions, leads to silo expert work and makes it more difficult to develop operational policy at the project level.

Elba Rahmouni: Who hasn’t heard or read during his working day the word validation, either in the form of a request received or to evoke the expectation of the competent authority? Coming from the Latin validare, which means to fortify, this word designates in contemporary language a procedure that strengthens an action. What do you think of our use of validation? 

It is, in my opinion, extensive and abusive. At first glance, it seems justified when it comes to ensuring that employees’ contracts comply with labour law, to supervise purchases made to ensure that the best price is sought and to minimise the risks of corruption through requests for quotations, or to ensure the quality of medicines through validation by the pharmacist.

However, building working relationships based on the request or expectation of validation presents several risks. Firstly, the decision may be suspended pending validation, knowing that doing nothing is a choice that has consequences on the real situation. Second, validation of a decision does not generate discussion – a discussion that is vital when it comes to exposing disagreement, justifying a refusal or convincing a colleague of the relevance of a point of view. There are certainly situations in which discussions have taken place before or are not necessary because the request for validation is a mere formality for sharing information and archiving it. But there are many other situations that would greatly benefit from an exchange of arguments between several people in order to arrive at an analysis or a decision enriched by the points of view of the different people involved (and potentially impacted), rather than validation or invalidation as it stands.

In La Revue Critique Borno, it is clear that when it comes to taking a position on the launch of an exploratory mission in the city of Bama, an exchange of emails requesting validation is akin to an atrophy of operational thinking.

Elba Rahmouni : Schematically, we can distinguish objectives and operational orientations. The former are the bureaucratic formulation of the latter. What is important for an objective is that it is, as we say in conventional management, SMART: Specific, Measurable, Accurate, Relevant, Time-bound. Real operational orientations are based on political choices – as such they are never neutral and do not leave one indifferent. At MSF it is not uncommon for operational managers to present their projects as “sanitized” objectives rather than as inspiring ideas that reveal bias. Why is this?

This is not unique to MSF in fact, but it is indeed surprising to note that even though we are not subject to the bureaucratic constraints imposed elsewhere by institutional donors, we adopt certain codes such as that of formulating project objectives that always look a bit like the same thing: “to reduce the morbi-mortality linked to xx in zone xx”. For example, it is often difficult, when reading a project sheet, to decipher what is really going on in it. In the same vein, when reading a sitrep, it is difficult to know if the teams are satisfied with their work, with the project, if everything is going as the team members want or not.

It seems to me that this comes from the fact that we have a false idea of what is professional. To be professional would be to adopt the most “objective” discourse possible, even if it means making simple, concrete and interesting ideas unintelligible. By mimicry, operational managers prefer to use passive formulas such as “it has been decided that” rather than saying “I/on/we want, think, judge”. These formulas and this lack of precise information give an appearance of neutrality to what should, on the contrary, be presented as a choice and assumed as such.

When operational managers are asked orally about their project, they have no difficulty in expressing their enthusiasm or the meaning they give to their involvement. This is not, therefore, an inability to think, but rather a habit of masking the role of individuals as if formulating a written opinion was unprofessional. This again refers to conventional management techniques aimed at eliminating the “human factor”. In my view, everyone should be encouraged to make their professional judgement visible in order to put facts, key figures and field observations into narrative form.

Elba Rahmouni: The representatives of the medical, logistics, human resources, finance, etc. departments have, over the years, increasingly positioned themselves as safeguards against arbitrariness, danger or waste, to the point that today they sometimes act more like internal gendarmes, reminding people of what cannot be done, than as support points supporting daily efforts to manufacture operations. Are the support functions then limited to vigilance? How did we get to this point? 

It would seem that each function has developed over the years with the aim of becoming, in its field, the most expert possible. This has been achieved by developing techniques, tools, standards, procedures and guidelines in order to build up a corpus of “business rules”. I would even say that gradually, each department has developed a main quality criterion that guides its work: the members of the HR function feel responsible for guaranteeing a form of equity between all MSF employees. For the members of the medical department there is the requirement to push MSF towards the quality standards recommended by the state of science in medicine. For the emergency unit, responsiveness is undoubtedly one of the most important quality criteria; etc…

The anomaly is that in doing so, we have put aside the profession that brings us all together within MSF, our common profession, that of making medical-humanitarian responses, which in fact lies in the art of combining all these functions by making compromises to set up beautiful medical-humanitarian operations. What I mean by this is that it is normal and inevitable that “conflicts of norms “2 arise between these different functions; but that we must arbitrate them in the sense of this profession that we have in common. For this to be possible, operational managers must also view their colleagues in support functions as persons whose professional judgement on operations is worthy of interest, and include them in operational policy discussions rather than presenting their decisions to them and asking everyone in their field to do what is necessary to make them workable.

1 Nicolas Dodier, “Contribution de Médecins Sans Frontières aux transformations de la médecine trans-nationale”, in Innovations médicales en situations humanitaires, Le travail de Médecins Sans Frontières sous la direction de Jean-Hervé Bradol et Claudine Vidal, 2009, pp.173-193.

2 Expression used by ergonomists, jurists and social scientists.

This interview, published on 28 February 2020, can be found on the MSF-CRASH website.

Marion Péchayre

Anthropologist of humanitarian action. Before doing research, Marion Péchayre worked as a program manager and coordinator in the field and then at the headquarters of Solidarités International. She has a PhD in Development Studies (SOAS University of London) and a Master’s degree in International Management (ESCP Europe). She teaches at PSIA and the Humanitarian and Conflict Response Institute (HCRI). Her main publications are: “Politics, Rhetoric, and Practice of Humanitarian Action in Pakistan” (in “The Golden Fleece: Manipulation and Independence in Humanitarian Action” Kumarian Press, 2012) and “Impartiality and Triage Practices in Humanitarian Settings. Le Cas de Médecins Sans Frontières Au Pakistan” (in “La Médecine Du Tri. Histoire, Éthique, Anthropologie” PUF, 2014).