No sanctuary in times of conflict:

1. No sanctuary in times of conflict: • A systematic analysis of security incidents affecting MSF’s medical mission from 2009-2013 in four highly insecure contexts • Maya Sibley • AAU analyst for MCUF • June 13, 2014 www.msf.be

2. BACKGROUND • MSF works in highlyunstablecontexts, and faces frequentacts of violence againstitsbeneficiaries and medical mission • Typology of violence against MSF ispoorlyunderstood – increasing violence isperceived, but not evidence-based • Launch of three-yearproject:

3. THREE RESEARCH QUESTIONS • How many and what are the trends in security incidents in Afghanistan, DRC, South Sudan and Kenya? • What are the consequences of security incidents in these four contexts? • What are the opportunities and limitations of SINDY reports with regards to the data needs of the MCUF project? • SINDY reports & semi-structured interviews for Q3 • Data collection

4. RESULTS & FINDINGS

5. MCUF INCIDENTS IN SINDY REPORTS

6. Locations • Reflect security strategy taken • INCIDENT TYPOLOGY • Trend over time • Baseline not established, but no increase observed over study period • MCUF hotspots Most perpetrators are unknownFrom those identified, the most common perpetrator is State Security Forces (25% overall) • Most frequent types of aggression • Afghanistan Armed entry 42% • DRC Robbery 34% • South Sudan Threats 38% • Kenya Robbery/Death threats 38% (each)

7. VICTIM TYPOLOGY National staff are the most common victims in absolute numbers but international staff are 5.1 times more at risk (p-value <0.0001, CI: 3.9-6.7) • Males are more frequentlyvictims in Afghanistan (59%) , DRC (73%) & S. Sudan (6%) • Women are more frequentyvictims in Kenya ( 67%, but sample size issmall)

8. INCIDENT TRIGGERS & CONSEQUENCES • The most common triggers and consequences of incidents were mapped (N, %) • Trigger: • Financial constraints60 (30%) • Active conflict & civil unrest 30 (15%) • General consequence: • Financial loss 64 (32%) • Compromisedquality of care 45 (23%) • Interruption of services 37 (19%) • Compromisedneutrality 32 (16%) • Types of consequence per victim: • Psychological 206 (62%) • Physical 65 (20%)

9. IMPACT HEALTHCARE DELIVERY & USE

10. SINDY REPORTING •  Half had not reported to SINDY a recent MCUF incident (4/8)  • TOP 4 REASONS FOR NOT REPORTING • MAIN SINDY SHORTCOMINGS FOR MCUF • Descriptive narrative • What should and shouldn’t be reported unclear • SINDY fields are vague • “Managing the security situation was a priority over reporting” • “Incidents occur so frequently that if we did systematically report, we would be constantly reporting!” • “I feel demotivated due to lack of SINDY report feedback and no security analysis from HQ.” • “SINDY is used only for reporting incidents which directly or indirectly have an impact on MSF activities.”

11. BIAS & LIMITATIONS

12. BIAS & LIMITATIONS • Data quality / Partial data • Inconsistent reporting • Lack of denominators • Victims • Time sensitive • Highly subjective • Limited capacity & know-how

13. CONCLUSIONS • First evidence-based mapping of violence directed against MSF and its beneficiaries. • Context-specific and general patterns of violence were identified, allowing development of more appropriate tools for the monitoring of “Medical Care Under Fire”. • Such monitoring is vital to sustain MSF operations in such contexts.

14. THANK YOU