Since 1971 Médecins Sans Frontières (MSF) has been providing emergency medical assistance to populations in crisis. In 2011 MSF has projects in more than 60 countries, and is one of the most widely known independent humanitarian non-governmental organizations (NGOs). While the core remit of the organisation is to provide emergency aid, MSF's work also encompasses provision of basic health care in places where this is insufficient or nonexistent, training of local medical personnel, bearing witness to and raising awareness of populations in danger Material aid is delivered concomitant to medical aid, and when necessary MSF teams are able to repair or develop medical and sanitation facilities.
While there is information available online, we considered that an interview with MSF would be of interest, in particular to GP trainees and GPs who are considering taking time out to work overseas. Two specific themes thought to be important to discuss were what opportunities exist for GP trainees to contribute towards MSF's work, together with accountability and sustainability aspects of MSF's projects. On 12 March 2010, Nell Gray, Field HR Officer at MSF UK was interviewed by Dr Luisa Pettigrew and Dr Ha-Neul Seo.
Ha-Neul Seo (HS): Firstly, we would be grateful for an overview of the application process for UK GP trainees and GPs within 5 years of qualification (First5). More specifically, are there any waivers to your essential criteria, and are there any additional assets that you would look for in a doctor specialising in general practice?
Nell Gray (NG): UK GP trainees would apply using the standardised process for all applicants, after FY2 plus at least 1 year of clinical work (MSF website).
There are no waivers to the essential criteria. UK GP training forms a good basis for an application as much MSF work is based in primary care. Recruitment is quite competitive, however, and so preferred selection criteria include additional skills such as language proficiency (especially French) and the Diploma in Tropical Medicine.
Other factors that MSF takes into consideration are applicants' availability, prior experience with MSF and individual motivation. One aim of selection is to balance candidates with a strong skill set with others who are very motivated and who may therefore become involved in multiple subsequent missions.
HS: Could you please tell us about a couple of recent placements matched to GP trainees or newly qualified GPs from the UK? What types of field work do you consider to be best suited to doctors in this specialty?
NG: There are no ‘typical’ placements for GPs. Three examples of newly qualified GP placements undertaken recently are general medical placements, a placement focused on nutrition (matched to the applicant who had experience in paediatrics), and disease-specific placement (for example, HIV, TB, malaria).
Each project has a clear strategic direction, with MSF clinical guidelines, protocols and procedures in place. MSF project teams number up to 30 people, within which a core team consists of a project coordinator, logistician, medic and nurse. Additional team members may include a mental health worker, water and sanitation engineer, and epidemiologist. The average ratio of international to local staff is 1:10. Project length is generally not less than 6 months, unless covering acute emergency work. GPs are usually more suited to longer projects of 9 months or longer
HS: What further training and support does the volunteer have access to, once in the field?
NG: In a small project team, it is possible for the volunteer to be the sole international medic in the field. Support is available from MSF's local medical team, project coordinator, head of mission and country management team, which is headed by a country director.
HS: Learning and development opportunities are detailed on the MSF UK website. On average, how easy is it for your volunteers to be able to attend the courses outlined?
NG: Volunteers train between missions, and are encouraged to focus on career objectives to direct their learning and training. If required, cover can be arranged during the project to release volunteers for training. MSF careers advisors aim to help people combine NHS and NGO work in the long term, if this is a career aspiration.
HS: Some regional training deaneries oversee Out-of-Programme (OOP) applications for GP trainees wishing to work with MSF and other NGOs. How often do you have such applications from GP trainees and how easy is it to match them to a mission for the timescales that they have in mind?
NG: These appear to be becoming more common, and it is usually possible to match people to a mission within the time frame, given plenty of notice. MSF is usually successful in matching GPs and GP trainees to suitable projects — it is rare not to be able to do so.
HS: If a successful match is not made for a GP trainee already on the MSF register, what are the reasons for this?
NG: This is usually due to two factors: the strength of the application and/or the limited time frame that GP trainees have within which to undertake an Out-of-Programme activity. Regarding the latter, applications are only seen 3 months in advance of the earliest proposed outgoing date and sometimes trainees prefer not to wait on a rolling application process. MSF suggests that applicants have a back-up plan in the event that their application is unsuccessful.
HS: Do you have information on what proportion of OOP field work projects undertaken by GP trainees are eligible to count for part of their GP training?
NG: No, MSF UK has not yet had a GP trainee who has had OOP experience with MSF accredited towards their CCT. Other specialities, including anaesthetics, infectious diseases and paediatrics have had their placements fully or partially accredited towards CCT. Often people do not wish to have their MSF project accredited, preferring it to be experience additional to their UK training.
HS: NGOs have been accused of diverting funds and staff that are often desperately needed to develop and improve health infrastructures in low and middle income countries. What is the MSF doing to address this?
NG: MSF's work complements, rather than replicates work done by ministries of health. While NGOs may pay local staff more than the Ministry of Health does, MSF has worked to standardise payment for local staff.
HS: How does MSF ensure that it is accountable to the people who use its services? Also, how does it decide which services to provide, and does it work to ensure the services it provides will be sustainable once they leave?
NG: MSF receives 80 to 90% of its funding from private donations, and has therefore been able to maintain impartiality and independence in its work while simultaneously maintaining agreements with local governments. In the case of treating rebel versus government soldiers during armed conflict, MSF provides impartial access to treatment for both parties.
MSF is a medical humanitarian organisation, with the idea for a project usually created locally. An MSF exploration team then visits the area to make an assessment of need.
Longer projects spanning several years may involve a considerable planning phase and the project itself may involve some developmental work. In contrast, urgent aid projects such as cholera outbreaks can be in place within 1 week of the initial outbreak. Recently in Haiti, an MSF team was on the ground in less than 24 hours after the earthquake.
During the planning phase, a timeline, long-term objectives and an exit strategy are formulated. At times, unforeseeable changes to the exit strategy are necessitated, such as in the case of an outbreak of military conflict.
Handover strategy spans approximately one year and is led by a specialist at headquarters. Handover may be to other developmental NGOs or to the Ministry of Health. After handover, MSF volunteers sometimes make return visits, depending on the long-term benefits of doing so. The purposes of return visits may include lobbying local governments and reviewing the need to send further specialists into the field.
HS: How does MSF promote training and development of local medical staff?
NG: A large part of the role of international MSF staff is training local staff. For projects in Swaziland, for example, evidence of teaching and training is specifically sought within applications, though often no formal teaching qualifications are required.
Some countries do not have a Ministry of Health. In Sudan, for example, many of the clinical officers are trained by MSF. Training of local staff occurs on the job, with MSF trainers helping staff to advance skills and career progression.
HS: Does MSF have policies in place that address the long-term health needs of the communities within which it operates?
NG: Before handing over a project, MSF ensures that local workers are fully integrated into it. Examples of increased awareness by MSF of accountability and sustainability are its HIV work in Myanmar and additional healthcare provision for a tuberculosis regime in Uganda.
HS: What, if anything, does MSF do to provide and develop primary care services?
NG: Large numbers of MSF activities are based within primary care; these are often in countries affected by conflict or in otherwise marginalised regions. In terms of advocacy, the problem of seasonal malnutrition in Niger has been addressed by MSF, which was able to act as a witness to the issue and lobby pharmaceutical companies for local access to medication. An MSF medical advocacy officer represents MSF in such matters and conveys such messages to target bodies.
HS: Thank you very much for your time today Nell. We've learned much more about MSF's work relative to what's available online, and we think it will be of great interest to GPs and GP trainees.
NG: Many thanks for coming and for your interest. We hope to continue to have excellent GP volunteers in the future.
