Learning the Lesson Is Not Enough

by Marilyn McHarg, Executive Director, Médecins Sans Frontières (MSF)

  • Project: Iraq Mission
  • Location: Iraq
  • Sector: Disaster Relief, Health and Safety
  • Professional Designation: NGO


Médecins Sans Frontières (MSF) is an organization that thrives on critical debate. Across the five MSF operational centres, we readily point out each others’ errors and shortcomings. When this dynamic is kept within the range of “healthy tension,” it serves the operational teams and the patients we treat. Everyone has to defend or adjust their actions in response to the criticism of colleagues. This pushes program quality to the forefront and reinforces accountability.

Added to this, MSF headquarters staff regularly visit field teams to ensure that our medical action adheres to the standards and goals of the organization. We also do formal evaluations, particularly after major emergencies. Some within MSF will say we don’t do enough evaluations. Having been with the organization for almost 20 years, I believe that we tend toward the opposite.

We do so many evaluations, alongside the regular supervisory visits, that our teams tend to be swamped with recommendations that risk being lost over time. Trying to prioritize and follow through on the multitude of well-intentioned insights can be overwhelming.

Learning lessons in MSF is not a problem. We learn lessons easily. Unfortunately, the same lessons are sometimes learned by different teams at different times. Our challenge is to swiftly integrate what we have learned across the vast MSF movement – more than 27,000 MSF aid workers served patients in over 60 countries in 2010.

As an organization that works largely in sub-Saharan Africa, historically we have focused on treating people with infectious diseases found in low-resource settings. This was reflected both in our clinical guidelines, and in our emergency medical supply kits containing standard drugs and medical supplies for the most common diseases.

In 2003, I was supervising MSF operations in Iraq. There, many of the illnesses people suffered were non-communicable, like heart disease and diabetes. In the aftermath of the U.S. invasion, our teams quickly positioned themselves with the usual emergency medical supply kits. Armed with malaria drugs and antibiotics, teams were not well prepared to encounter the kinds of health needs associated with middle-income countries, namely non-communicable diseases.

It was a frustrating situation. Not only were we unprepared, but our teams struggled with the change in focus. We needed substantial additional supplies to make our medical action fit the main needs. Even more frustrating was when we realized that an evaluation of our previous work in Kosovo had already highlighted the importance of being ready to treat chronic, non-communicable diseases in middle-income settings.

But still we failed to learn our lesson, and repeated the same mistakes after the 2010 earthquake in Haiti. From “Haiti One Year After” (2011), the report on our response:

Furthermore MSF did not have the appropriate medicines on hand in the emergency phase to care for patients suffering from non-communicable conditions such as hypertension, diabetes, and epilepsy. Of 850 patients treated in one location between March and September, there were 72 cases of hypertension. Recognizing this shortfall in the package of available care in some MSF medical structures, the organization is already evaluating the feasibility of including chronic disease kits in the emergency preparedness stocks it maintains in different countries.”


With all the competing pressures and impossible choices, we had failed to prioritize patients with non-communicable diseases caught up in emergency situations. Our planning was still determined by conditions in the places where MSF had worked for most of its history, and by the epidemiologic patterns encountered there.

The balance is shifting, however.  As we encounter more and more patients with non-communicable diseases, and as we strive to better meet our patients’ medical needs, MSF is moving toward more holistic approaches and integrated medical action, rather than vertical, infectious disease-focused strategies. Consequently we are shifting from providing basic care for many, to treating fewer people more comprehensively.

This shift has helped the organization to take on the challenge of treating patients with non-communicable diseases. After the earthquake and tsunami in Japan in April 2011, MSF assisted patients suffering from these diseases from the start, demonstrating that we are becoming better prepared to meet longer-term patient needs under the temporary circumstances of an emergency.

However, this still leaves the question of how to rapidly integrate lessons learned on a more systemic level, right across the MSF movement. As the field evaluations and debates around quality continue, the organization has started to place more emphasis on centralized mechanisms. Step by step, evaluations are becoming more centrally driven, and operational progress is being monitored and documented for future reference.

This increasing centralization is exemplified by a new, annual mutual accountability exercise between the directors of MSF’s operational centres. By placing accountability at a more central level – with the participation of board presidents, general directors, operational directors and medical directors – we think that valuable lessons requiring concerted action will be better integrated across the movement.

The trick will be to ensure that, even as these new mechanisms help us act on the lessons we’ve learned, we still maintain a healthy tension and the room to challenge one another through our traditional monitoring processes.  Keeping this balance will allow MSF teams around the world to assist people in need with the most medically relevant quality care possible.


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  1. connie says:

    Hoefully this will resonate with other groups sent in after disasters.

  2. Lama says:

    Isn’t the largest failure that MSF, and other similar groups, rush into a situation that they know nothing about? Perhaps spending 1 or 2 days before sending in the full teams would better prepare the teams that are coming, and also not waste $$$ on medicines or equipment that are not needed. Additionally, partnering with local organizations more would be a key way of ensuring that the incoming team is more aware of the issues at hand and not making assumptions. Believe it or not, most countries have some doctors.. the question is, is MSF connected to them and does it communicate with them?

    • lili says:

      For information: MSF is always working together with local doctors and other valuable local staff members. Often MSF is also already in the country running other projects when the disaster occurs, with a good knowledge of the context, a network in place and already with hundreds of national staff. This was the case in Haitias was the case in Haiti for instance.

      It is of course still questionable, even more so maybe, how MSF still failed to have an adequat respons when it came to non communicable diseases and also to some extent to pregnant women. (still the efforts made to meet the enormous surgical needs was huge and may to some extent have affected our ability to see beyond that. Still, not a valid excuse.) It is true we should have learned our lesson by now and we should be much better in cenetralize the knowledge and make sure our guidelines and systems are updated accordingly. MSF has become so big so fast, it is in my view one of our biggest challenges to stay coherent, with an effective communication and understanding on lessons learned throughout the mouvement.

  3. Reem says:

    How can large organizations, such as MSF with 27,000+ aid workers around the world, better manage the knowledge and experience they gain from one failure to avoid it in a subsequent situation? Marilyn mentions that the failure in Iraq had already occurred in Kosovo, and was, in fact, repeated in Haiti after Iraq. An organization can centralize the knowledge gained through its fieldwork experience, including successes and failures, through an upward feedback mechanism to management who should apply analogous logic to upcoming projects.

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