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 safeguarding1 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.