Opinion Without Borders: Reforming the Governance Structure of a Large International NGO Kris Torgeson

1. Opinion Without Borders: Reforming the Governance Structure of a Large International NGO Kris Torgeson Transnational NGO Initiative, Maxwell School, Syracuse University 22 October 2013

2. Today’s Presentation • Introduction to MSF • Why reform? • Challenges • Process • Results • Lessons Learned • Questions

4. MSF founded in 1971 in the wake of the Biafra Crisis

5. MSF Charter “…assistance to populations in distress” Doctors Without Borders/Médecins Sans Frontières (MSF) is a private international association. The association is made up mainly of doctors and health sector workers and is also open to all other professions which might help in achieving its aims. All of its members agree to honor the following principles: Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions. Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions. Members undertake to respect their professional code of ethics and to maintain complete independencefrom all political, economic, or religious powers. As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them. “…neutrality and impartiality” “…medical ethics” “…independencefrom all political, economic, or religious powers.” “…As volunteers, members make no claim for themselves”

6. Neutrality Democratic Republic of Congo, 2008

7. Impartiality Liberia, 2007

8. Independence NW Frontier Province, Pakistan 2009

9. MSF MISSIONS AROUND THE WORLD • Medical programs in more than 70 countries in 2012 • 31,820 field positions- 8% of field positions filled by international staff • More than 8.78 million patient consultations (95% OPD, 5% IPD) • 78,500 major surgeries (many C-sections) • 185,400 births (includes C-sections) - 784,500 antenatal consultations

10. MSF-International Funding 2012 Other NGOs or Associations – 2% $21,200,000 Institutions and Governments** – 9% $109,100,000 Individuals, Corporations, and Foundations – 89% $1,106,800,000 Total Revenue $1,237,100,000 **includes ECHO and the governments of Canada, Germany, and the UK among others

11. MSF-USA Funding 2012 Foundations – 4.6%$8,641,990 Corporations – 3.3%$6,325,563 Individuals – 92.1%$174,337,902 Total Revenue $189,305,455 * No US Government funding

12. MSF-International Expenditures 2012 Management – 6%$74,700,000 Fundraising – 13%$164,700,000 Program Activities – 81%$1,005,900,000 Total Expenditures $1,245,300,000

13. MSF-USA Expenditures 2012 Management – 1.33%$2,635,325 Fundraising – 12.34%$24,517,940 Program Services – 86.33%$171,530,348 Total Expenditures $198,683,613

14. Armed Conflict Sri Lanka, 2009

15. Malnutrition Niger, 2008

16. Epidemics Nigeria, 2009

17. Natural disasters Haiti, 2010

18. Exclusion from Health Care Morocco, 2005

19. Interventions • Primary health centers • Mobile clinics • Hospitals • Surgery • Vaccinations • Nutritional support • Infectious disease outbreaks • Mental health • Water and Sanitation

20. Logistics France

21. Kits & Guidelines

22. Bearing Witness New York City, 2011

23. MSF Aid Workers Nurses Physicians Anesthesiologists& Nurse Anesthetists Surgeons

24. MSF Aid Workers Pharmacists Lab Techs Mental Health Professionals Midwives Epidemiologists

25. MSF Aid Workers Logistics, Water/Sanitation, Construction, Electrical, and Mechanics Experts Finance, Human Resources, and Administration Professionals

26. MSF Aid Workers

28. MSF Governance Reform Process (2009-2011+) • Previous structure • Why reform? • Challenges • Process • Considerations/Debates • Results • Lessons Learned • Questions

30. MSF Associative structures – pre 2011 • Associative movement - 19 associations world-wide • Each association a separate legal entity • Each association has individual membership , meeting at least once per year to elect and guide the board • Each board has a president that represents the association locally and at international level • All MSF associations members of the ‘MSF International Association` registered in Switzerland • Each president single vote at International Council

31. Executive Operations & Support- pre 2011 • 5 operational centers (OCs): Paris, Brussels, Amsterdam, Geneva, Barcelona • Supported by 14 partners sections • Moratorium on new sections and OCs • Each OC different governance structure, but largely autonomous to make own, yetincreasingly interlinked and interdependent • International operational decisions made on consensus basis – ExCom, ExDir, DirOp, DirMed • Accountability to individual boards, not to any international governing body

32. How was MSF set up internally? INTERNATIONAL COUNCIL ICB All sections represented on IC via Presidents EXDIR/EXCOM Consensus based IO Access Campaign DIROP/MEDIR/LOGDIR/HR/Other Platforms Consensus Based/variable clarity of role 9 S I N B HK D L UK H De C A CH US Au F J Gr E OCB Gathering OCP OCBA OCA Board OCGCong OCB Board +UAE +SA & Br OPERATIONS OPERATIONS OPERATIONS OPERATIONS OPERATIONS

33. Why reform? Recognition that MSF not adequately organized to address external & internal challenges that were beginning to negatively impact ability to deliver on its mission

34. New types of emergencies: migration, climate change, urbanization... Rise of strong states - decline of Western dominance: - Increased state capacity, control & coordination in developing countries - NGOs seen as ‘implementing partner’ Changed perception of NGOs - Humanitarian organisations & their ‘charity’ seen as form of neo-colonialism - long term development approach more appreciated than short in & out - NGOs expected to be ‘agents of change’ - Increased number of NGOs leads to confusion & misunderstanding about NGOs’ specific identity Increased complexity of medical work: HIV 2nd line, MDR-TB, chronic diseases… Rise of influential Global Health Actors: Global Fund, Gates Foundation… International Criminal Court & criminalization of actors: NGOs perceived as threat to authorities in place Weakening of international humanitarian law: lack respect aid workers Global and instant access to information Key external challenges - Operations

35. Key external challenges - Resources Human Resources Need for highly skilled & experienced workers Difficulty to recruit & retain the right HR despite many HR departments Private income Global financial crisis Competition among international NGOs Need for investment in new markets Institutional Funding Smaller pot of funds Donors demanding more visibility (eg: ECHO)

36. Key internal challenges FIELD OPERATIONS • Increasingly complex settings & strong governments require more robust field management frameworks • advocacy and public positioning slow, uncoordinated • Increased need to engage with the external actors • Duplication of support structures • Needmechanisms for timely conflict resolution HEAD QUARTERS • Growth • Weak coordination across all sections, duplication of efforts and HQ growth>Field growth • International platforms are not empowered to be decision making • An increasing number of layers in HQ results in increasing mgt complexity

37. Key internal challenges MOVEMENT • A ‘sense’ of co-ownership but a reality of sectionalism. • Lack of meaningful accountability at international level • Lack ofrespected authority at international level ASSOCIATION • What constitutes “meaningful membership” in an MSF association • New associative initiatives are being established & called for without a governance structure that reflects the ambition of inclusiveness & bringing in new voices

38. Not first time MSF had questioned its identity and governance…

40. MSF Governance Reform Process (2009-11) • Agreement on framework at launch: • Diagnosis: agreement on need for reform • Scope: how far reaching • Ambitions: how to measure success • Process: who involved, how consultative, decisions • Implementation: how, who, when • Utilizing phased/staged approach • Identify question • Consultation/research • Decision

41. Diagnosis (eg. Phase 1) • QUESTIONS: What are the key challenges to the organization that current structure not adapted to address? What is working & should be preserved? • CONSULT/REASEARCH: Carry out assessment of current structure: strengths & shortcomings • Working group on diagnosis • Review of sections • Review of decision making platforms • DECISION: small tweaks not enough, launch more wide-ranging reforms with agreed on ambitions

42. The Ambition of the Governance Reform Process Any future organizational setup must enable MSF to: • develop and implement strategic movement-wide operational orientations • develop coherent operational strategy and representation in highly exposed contexts • ensure timely public positioning on critical issues • efficiently and effectively generate and allocate our collective resources in line with the ambitions of the MSF social mission • achieve timely conflict resolution, especially in situations that pose a threat to the assistance or identity of the organization

44. 5 Directors of Operations– Dec 09 “The purpose of any internal reform or change in model can only be to improve MSF’s action in the field and its capacity to respond to the challenges listed above. The relevance of any governance or organizational model should be tested in relation to this principle.”

45. Process – key challenges • Agreeing on objectives, need for reform • Carrying out wide consultation, • Managing opinions and input • Not letting process overwhelm all else • Using minimal resources • Ensuring process in synch w/ organizational culture • Keeping up momentum, showing progress • Making decisions & not going back over them • Communication

46. Process – key elements • Timeline & methodology • Phased: question, consultation, decision • Broad to narrow, Associative to Executive • Working group • Representative, high level and internal • International leadership • Minimal external consultant support • Consultation • Broad & inclusive • in sections, platforms, groups, field at specific points along way • Communication • Dedicated effort to communicate opportunities for input & progress reports • Milestone recommendations or decisions at major international meetings • Maintain pace and involvement • Implementation plan

47. Key Debates in MSF Reform • “One MSF” , merging operational centers, sections • Decision making • International vs operational center or section • Centrality vssubsidiarity • Consensus vs voting • Who involved in making decisions • Enforcing decisions • Collective vs individual : what best done together, what not? • Preserving & fostering innovation, capacity to act • Increasing efficiency • Mutual accountability • Co-ownership • Conflict resolution • Growth • Inclusivity

48. The Results June 2011 Geneva – Unanimous agreement on new statutes & structures & implementation timeline

49. Structure - MSF International Institutional Members THE MEMBERS President President THE INTERNATIONAL GENERAL ASSEMBLY (1x year) 2 Representatives per Institutional Member 2 Elected Representatives 5 Op Directorate reps + 6 elected + President THE INTERNATIONAL BOARD (6-8 x year)

50. Main outcomes • Agreed upon new statutes & structures meeting initial ambitions • Clarity on what decided at international level, how decided, how enforced and what is NOT decided collectively • Clearer and broader criteria for new and old associative membership in MSF International • A balanced, credible international board with more authority to ensure accountability, guide the executive and resolve conflicts • Strategic high-level focus for International General Assembly (not all involved in all decisions) • Commitment to develop strategic ambitions for MSF to guide the movement over the coming 5-10 years • Executive reforms decided on in parallel to complement associative reforms