Paper: The power behind humanitarian INGOs. The case of Médecins Sans Frontières

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Paper authors Eduardo Wehbe
In panel on Building a Knowledge Base: Theories and Methods in Humanitarian Action
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Abstract: This work intends to go beyond existing research on international humanitarian Non-Governmental Organizations (INGOs), which in general wonder about the type of power they hold, its sources or the conditions for its emergence, to inquire about its practical application in the ground. In this way, the questions that guide this proposal are: what are the mechanisms and logic that promote the best conditions for the use of power by humanitarian INGOs to fulfill their mission? How are these strategies implemented in the field? and what are its consequences?
In order to increase their power, as a natural response to structural forces that drive the competition for survival but also to fulfill their missions, humanitarian INGOs define and develop capabilities that can be defined from their foundation or be the result of the conscious effort of their leaders to generate levers of power. In turn, the development of authority attributes will be related to the interaction with other actors, that is, linked to the criteria of relational authority such as expertise, deference, or negotiation skills. The probability of exit in the application of authority attributes that humanitarian INGOs put forth on the ground to fulfill their missions and commitments will depend on capabilities developed. In the end, the strategies applied to deploy these attributes will define the relationship logic of humanitarian INGOs with their stakeholders in the ground; that is, cooperation, confrontation, and competition.
These statements will be addressed through the case study of a humanitarian INGO, that is, Médecins Sans Frontières (MSF) from the in-depth analysis of 3 scenarios where the organization intervened: a) The Ebola epidemic in West Africa (2014-2016); b) The refugee crisis in the Mediterranean (2015-2016) and c) The armed conflict in Yemen (2015-2016).

Keywords: Médecins Sans Frontièrs. Authority, INGOs, humanitarian, capabilities, attributes, relationship.

Humanitarian action has increased significantly since the end of the Cold War for different reasons: more internal conflict within countries, higher occurrence of natural disasters, increase in available funds for crisis, expansion of communications, alleged greater empathic capacity or growing power of influence of the humanitarian organization, among other things. In each of the humanitarian crises that break out somewhere on the planet, the growing role of humanitarian actors to assist affected populations and thereby impact on local society and finally on international politics becomes more evident, particularly international Non-Governmental Organizations (INGOs). In recent years, humanitarian aid INGOs have been responsible for channeling an average of around 35% of total funds into projects to assist vulnerable populations around the world.
Although there are remarkable differences between the most representative humanitarian INGOs of the humanitarian system , they have distinctive characteristics from the rest of INGOs, derived mainly from the particularity of their mission, that is to save lives and alleviate human suffering in specific spaces such as refugee camps, hospitals in remote regions or even on ships in the middle of the Mediterranean Sea. Hence, they face particular challenges to fulfil their missions, such as logistic, financial, or legal difficulties in accessing to affected populations, to the need to overcome the inherent asymmetric relationship experienced in most of cases of negotiations with actors who hold real power on the ground. Further driven by competition and pressure from donors, common to other civil society organizations, humanitarian INGOs are induced to increase their power resources to face these challenges that, if not overcome, they can translate directly into the loss of human lives due to lack of action or the disappearance of the organization. The features of each of the humanitarian INGOs will define the strategy to deal with these challenges.
In the search to understand the nature of these non-state actors, studies on INGOs have received increasing attention in recent times, although with some nuances. Attention on humanitarian INGOs has been increasing in the academic world, but the ever-changing situated context in which they operate presents the greatest difficulties for understanding the meaning or intention of their actions. Thus, any attempt to interpret the political processes in which humanitarian INGOs are involved because of the exercise of their activities on the ground will tend to be very generalizable or otherwise, their conclusions will be adjusted to specific conditions. This promoted more efforts to the study of INGOs oriented towards the defense of the environment or human rights whose arena do not suffer this "limitation" by favoring the journey of interpretations to other organizations and contexts with a certain degree of security. This is the other dimension of the challenge of humanitarian INOGs study, in addition to the access to information and data from first source for contexts analysis.
A starting point for an approach that seeks to account these issues refers us to Jennifer Rubenstein's vision of humanitarian INGOs, those she does not consider exclusively them as angelic Samaritans or machines for doing good, nor as organizations driven by the benefit of other political actors, but rather organizations that seek to do good but face limitations and unwanted effects of their action that lead them to face extremely challenging ethical dilemmas. Rubenstein recognize their political agency in humanitarian action arguing:

They have the discretion or leeway or understanding sufficient to identify the main differences and implications of the various courses of action they may pursue

However, it is necessary to understand that no humanitarian INGOs have sufficient power to choose the courses of action to take in any circumstance and context, even those that, according to Stroup and Weng, manage to achieve the status of leading organizations that ensures them to receive deference from a diversity of audiences . Hence, like other actors in international politics, humanitarian INGOs must try to maximize their capabilities to expand their margins of action. To do that, they develop different authority attributes according to their nature and strategic choice to be deployed before stakeholders to fulfill their mission.
Taking into account the heterogeneous character of INGOs, a central argument of this work is related to the ability of each of these organizations to develop capabilities and institutionalize it to navigate through the challenges that they face considering the structural restrictions to which they are exposed. In this way, it is intended to answer the following questions: what are the mechanisms and logic that promote the best conditions for the use of power by humanitarian INGOs to fulfill their mission? How are these strategies implemented in the field? and what are its consequences?
The challenge of accounting for these questions is presented here through an in-depth analysis of political process of configuration, institutionalization, and implementation of power factors by one of the most representative organizations of humanitarian INGOs such as Doctors Without Borders .
Conceptual map

Thesis: This work seeks to demonstrate, through the case of MSF, that humanitarian INGOs, to successfully fulfill its mission, develop capabilities through organizational adaptations that allow them to dispose authority attributes to be exercised strategically in a combined way in their relationship with their stakeholders, configuring, in this way, a relationship logic determined by this political process.

Theoretical framework:

Power: The correct approach to understand the construction and exercise of power carried out by humanitarian INGOs implies assuming a definition of what is understood by power. Here power is understood as authority that includes a relational dimension but also a material one represented by the capabilities that actors hold to support the aim of influencing others. In this way, authority is not something fixed or static, but rather a given construction from the social relations that humanitarian organizations establish in the field.

Organizational change: Organizational change can be understood as any change in the formal structure, the organizational culture and the objectives, the program or the mission occurred in an evolutionary or revolutionary way, planned or unplanned that pursues the increase of possibilities of an organization to achieve your goals.
INGOs organizational structures reflect the power and interests of the actors and determine the way they frame social problems and the strategies deployed on the ground. Certain organizational forms can be beneficial to carry out some activities such as service provision, promotion, or fundraising. This would explain some degree of structure variation but also similarities among humanitarian INGOs and behavior in adapting best to environment.
Variables and processes: To increase their authority, as a natural response to structural forces that promote their competence for survival and the fulfillment of their humanitarian mission, humanitarian INGOs define and develop capabilities. When talking about capabilities, we refer in general to the conditions created by the leaders of organizations to fulfill their objectives or missions. These capabilities are related to the nature of the organization or are acquired throughout its life. Although it is possible identify many capabilities according to the nature of each the organization, some of them are common to all organizations as leadership, economic independence, contact networks or specialization. In the case of MSF, we consider its nature as single-mandate organization as a capability defined since its creation to focus mainly on humanitarian crisis and not on another activity such as development or the promotion of human rights and. Therefore, rely mainly on humanitarian principles to justify his actions. In the same way, the medical care specialization gives MSF distinctive tools to exercise their authority against its stakeholders particularly in complex contexts where the health of the population is in imminent danger. On the other hand, both economic independence and the development of logistics capacity are the product of strategic decisions by the authorities of the organization, achieved over the years to equip itself with authority tools to fulfill its mission. In summary, capabilities - common to the organization in all contexts - define the conditions of possibility in which the authority attributes can be exercised in the field.
Authority attributes: differ from capabilities because their development and application are related to interaction with other actors, that is, linked to the criterion of relational authority. It is not a question of characteristics of a given organization, but of the conscious effort to develop power factors to impose their will in scenarios in which they constitute a differential. Thus, the authority attributes that humanitarian INGOs deploy on the ground will depend on the capabilities developed. This will allow, in a kind of natural selection, that only humanitarian INGOs with some specific attributes can face the challenges of intervening in certain humanitarian crises. In the case of MSF, three authority attributes put into play combined in each scenario are analyzed: expertise, deference and access.

From one side, expertise understood as scientific knowledge legitimized by the interested parties, became a significant authority attribute, if not the most important in its relationship with third parties . Thus, "know to do" can constitute a critical power factor in some circumstances such as defense of human rights, manipulation of land mines or care of Ebola patients. Thus, the vast medical expertise gained by MSF for more than 50 years in armed conflict, epidemic or natural disasters are determinant in their relationship with stakeholders.
From other side, the key point that define deference is voluntary subordination to another, that is, consent. If an audience confers authority on an actor, it makes it clear that this actor cannot be ignored, even if his points are controversial or problematic. The granting of authority by the audience to INGOs allows them to exercise authority within and outside of the direct relationship with a given audience. INGOs have agency in the sense that they can become more likely candidates for deference, but the effectiveness of these strategies depends on how they are perceived. For all this, deference can be considered a critical authority attribute when the crisis to be addressed attracts the attention of world public opinion, since it amplifies the probabilities of increasing the political agency. For humanitarian organizations as MSF, possibility of producing changes in political scenario from denounce and témoignage is the other side of direct humanitarian assistance.
Finally, humanitarian access can be understood as the ability of a humanitarian organization to overcome difficulties on the ground to provide humanitarian assistance considering humanitarian principles. To overcome difficulties and gain access, the main tool available to humanitarian actors are humanitarian negotiations. The persistent challenge is to overcome the asymmetry of power inherent in these negotiations and reach sustainable and sustained over time agreements that allow continuous access to populations in need. Strategies learned by MSF from years of experience in unstable contexts to obtain access to vulnerable populations represent an asset against actors with veto power on the ground as counterparts in humanitarian negotiations.
Understood in this way, authority attributes can and certainly are combined with other on the ground in such a way as to obtain the best balance of forces against their stakeholders. Hence, a relationship logic can be identified for each combination according to the preeminence of each authority attribute.

Relationship logic: The options defined here for the relationship of humanitarian INGOs with their stakeholders on the ground range from cooperation and confrontation to competition. Cooperation will occur when, even in a situation of asymmetry in the provision of resources, the actors agree on objectives and means to address a problem or urgent crisis. At the other extreme, confrontation, will take place when there is no agreement on objectives or means. The source of this confrontation may come from restrictive acts on the part of the actors with power on the ground or from the open opposition of humanitarian INGOs. The common factor here is the perception of other as a threat. Finally, competition is the scenario in which the actors identify with the objective but differ in means to face a problem. This last type of relationship is typical of armed conflict contexts
In the scenarios studied, MSF has as a stakeholder not only States as recognized political entities and with a monopoly on violence , as in the case of the Ebola epidemic, but also supranational organizations such as the European Union in the case of assistance to migrants in the Mediterranean or armed groups that hold the monopoly of violence in any part of the country, as happens when dealing with the armed conflict in Yemen.
In this way, the sources outlined on the relationship of INGOs with the States seem not to be fully adjusted to address the nature of that established by MSF in the scenarios analyzed. This can be saved if we understand that the relationship is established with those who hold the monopoly on violence and have the capacity to determine the conditions that humanitarian INGOs must comply with on the ground or alter the environment. However, supranational organizations or armed groups do not have all the characteristics that make a State such as a bureaucracy. A matrix that attempts to capture the main features of the relationships between humanitarian INGOs and the actors that hold the monopoly of violence must take these specificities into account.

Selection of comparative scenarios

The work plan to address the authority attributes and relationship logics that correspond to them includes an in-depth analysis of 3 scenarios in which MSF deployed missions:

The choice of cases responds to the claim to address the construction and exercise of authority of this type of humanitarian organization in missions of a different nature, not only because of the context but also because of their configuration. Hence, the variation occurs in the contexts and their specific characteristics to which the organization must respond and not in the timing of its deployment, since these are cases in which MSF acted simultaneously during the years 2015 and 2016. However, for each of the scenarios, regularities and common factors typical of humanitarian interventions can also be identified.

Research technique and study methodology

This work is mainly based on qualitative techniques. The central tools are semi-structured interviews with MSF humanitarian professionals, participant observation as part of the author's work as international staff in the organization, and the survey of material edited mainly by MSF, as well as other humanitarian INGOs as a reference and bibliography specialized in humanitarianism arena.
The process tracing method is a fundamental part of this work. As a qualitative method used to test or create a theory “inductively uses the evidence within a case to develop hypotheses that may explain the case” . The process tracing method is particularly suitable for generating new variables, typologies or hypotheses based on detailed observation of the sequence of events of a case over time. Through monitoring the process in the three scenarios, it is intended to demonstrate both a correlation between the possible causes and the observed results and a causal mechanism between independent and dependent variables such as capabilities and authority attributes and logic of relationship with other actors. The identification of these logics in the intervention of an INGO in a humanitarian crisis is the objective of using this method in this work.
The comparative case study methodology used in this article tries to overcome, to some extent, the limitations that affect the study of humanitarian INGOs. It proposes a causal relationship between capabilities, authority attributes and relationship logic in which context variation is contained in the choice of differentiated strategies that combine these variables to fulfill their mission while capabilities have in the organizational change their main source of variation. In this way, leaving to the strategies the naturally variable role of interpreters of the different contexts through which the organization expresses itself in the field to fulfill its mission, it is possible to analyze authority attributes as characteristics of the population of humanitarian INGOs that can be found to a different extent in each of them.
Once the terms and the conceptual map of this work have been defined, a proposal for the application of the conceptual body to the selected cases is presented below:

Independence Logistic
Mandate Specialization
Authority attributes
Scenarios Expertise Deference Access
Ébola Epidemic in Western Africa (2014-2016) xxx xx x PRIORIZATION
Mediterranean Refugee Crisis (2015-2016) x xxx xx
Armed conflicto in Yemen (2015-2016) xx x xxx
Cooperation Confrontation Competence
Relantionship logic


The organizational adaptation of MSF
The analysis of the evolution of MSF from a meeting of the wills of doctors and journalists "with common and supportive purposes" to becoming a leading INGO in the humanitarian system makes it possible to identify the organization's own capacities. These determine the effectiveness and conditions of exercise of its agency vis-à-vis third parties based on different strategies for the use of its attributes of authority. Without these conditions of possibility, the organization would not have enough leverage to exercise its authority attributes.
In the development of this section, the milestones that constitute elements of rupture and that allow sustaining the determined stages are presented :

INCOME 100 M 340 M 885 M 1.901 M
INTERVENTIONS 170 232 436 470
STAFF 1.300 15.125 31.882 41.014
Development of capabilities and attributes
Born with the intention of becoming a medical-humanitarian INGO while maintaining its associative dimension, MSF turned out to be the product of the merger of two groups of volunteers trained in the heat of experiences of humanitarian crises in third world countries. Medical specialization is inherent to its creation and continues through the organization to this day beyond the development of other additional capabilities such as its logistics architecture. However, the decision of its leaders to adopt the format of an organization with a single mandate or “Dunantist” focused on emergency interventions, begins to be imposed with more determination once the internal debates that defined its nature were concluded . The develop of its logistics capacity is intrinsic to the progressive expansion of its operations around the world and is a factor that can be found in other humanitarian organizations as well. The establishment in 1986 of MSF Logistique , a satellite organization of MSF, was the first of a series of specialized logistics organizations that will shape the architecture of its supply and storage system. Finally, although economic independence was conceived from the beginning, its practical implementation took several years during which the organization depended heavily on institutional contributions from the French government and the European Union . While the organization made constant efforts to develop campaigns to attract private donors, the final impulse came from the notoriety and international prestige that gave it the distinction of the Nobel Peace Prize in 1999, after which institutional funding began to flow. decrease to represent today around 3-4%.



Medical expertise by areas was the result of MSF participation in interventions of a diverse nature since its creation, such as care in refugee camps, armed conflicts, or natural disasters. The expertise in care for Ebola patients had interventions in previous outbreaks as the main engine for its evolution that were capitalized on internal develops from procedures manuals, constant training, creation of emergency teams of specialists and promotion of scientific research.
For their part, the deference of other actors towards MSF was based on their continuous appeal to humanitarian principles and the independence of action in their interventions. The organization's claim to deference can be said to arise from a clear action of denunciation or testimony (témoignage) that constitutes the other half of its nature. The development of this demand in MSF combines, since its inception, high visibility, and high impact denunciation actions with the launch of massive awareness campaigns and the periodic publication of Reports to support its missions on the ground. The success of these actions can be perceived today since MSF is an unavoidable actor in the humanitarian system.
Finally, the ability to gain access was consolidated as an attribute of authority with field experience in different scenarios: armed conflicts, natural disasters, refugee crises, where both rejection and acceptance drove its development. Aware of its centrality for the performance of its mission, this characteristic was promoted by MSF with the constitution of teams specialized in negotiation and access manuals and procedures.
An interpretation of the evolution of these attributes can be seen in the table prepared from an analysis of the variables that define them from the origin of the organization:



Application of the model to selected interventions

1. Ebola epidemic in West Africa:

Ebola Epidemic in Western Africa (2014-2015) XXX XX X
Mediterranean Refugee Crisis (2015-2016) X XXX XX
Armed Conflict in Yemen (2015-2016) XX X XXX

The Ebola Epidemic manifested itself in Guinea Conakry at the end of 2013 but was only identified as such in March 2014. Ignorance and disbelief that a virus that was assumed to be far away could spread in West Africa produced a delayed effect in its detection and with it the unbridled expansion of contagion chains in the region. By May of that year, Guinea Conakry, Liberia, and Sierra Leone had declared a health emergency due to the presence of the virus in their countries, and by July, alarm and fear had spread throughout the world due to the impact in the media. However, it would take time for the international community to react to reach a joint way out of the crisis, driven by fears of the spread of the outbreak beyond the confines of West Africa.
The death toll reached a total of 28,616 cases, representing more than 11 times what was observed in the previous 24 outbreaks and 67 times the size of the largest outbreak to date. The fact that the outbreak was caused by the most lethal strain, that is, the Zaire type, exacerbated the general scenario, giving rise to fear and complete immobility of the main actors. Although the mortality rate culminated around 40%, in its first stage it far exceeded 70%.
To present an overview of the conditions and characteristics of this scenario, the table below shows the main milestones of this humanitarian crisis for the period analyzed from March 2014 to June 2016:

MSF's presence in West Africa since the hard years of the civil war in Sierra Leone and Liberia with active missions in the region at the start of the Ebola epidemic was a great asset. On the one hand, it gave the organization a realistic vision of the serious limitations of the health infrastructure in the countries most affected by the epidemic, and, on the other hand, it facilitated the acceptance of the organization's activities by a large part of the population. which allowed him to deploy a rapid response. If we add to this the experience acquired in interventions in previous outbreaks, the organization recognized early dimension the magnitude of the threat that the region was facing and took concrete actions to resolve it.

1.1. Authority attributes: The Ebola epidemic represented an opportunity for MSF to use the authority gained because of its medical expertise in notoriety and influence in other audiences, that is, taking the scale from the local to the global to leverage its actions in the land. Despite the high deference of the most important audiences achieved by the organization and the fact that the denunciation speeches were perhaps stronger than those undertaken in the Mediterranean refugee crisis, these were relativized due to the importance of medical expertise in the context of the epidemic. The international president's speech before the UN Security Council or the statements in the public media before a sensitized world public opinion had a high impact. For its part, it was not necessary to deploy many strategies for access due to the type of mission. In this sense, the problems were mainly caused by the rejection of the population in the face of disbelief or mistrust, while the governments expressed themselves by evasive maneuvers in the face of evidence in the early stages.
Expertise –in a broad sense, but with medical knowledge as the main focus- played a preponderant role, naturally because it is a global health emergency. The willingness to intervene, the experience and the absence of other actors strengthened this role as MSF had developed sufficient capabilities to assume it. This decision also considered the loss of prestige that withdrawing from an emergency would represent in which the eyes of a variety of audiences were focused on the organization. The fact that it remained the only organization with the ability to treat the disease allowed it to establish conditions for its counterparts that were not always met in other contexts.

1.2. Strategies: MSF established a series of strategies based on their capabilities and attributes of authority based on a reading of the context and evaluation of the implications of their action on the ground. The deployment of context-sensitive strategies reflects this position for MSF in this case:

Ebola Epidemic in Western Africa (2014-2016) Provision of public goods
Participation in the development and implementation of experimental treatments and vaccines
Training of specialized human resources
Early reaction and constant monitoring

In all the strategies, the privileged position of MSF with respect to its stakeholders is present in the form of training, active participation in the development of vaccines or early reaction to warn about the harmful potential of the outbreak. Each of them also contains elements of the three authority attributes prevailing medical expertise. In the training and formation of resources and the permanent vigilance by monitoring contagion chains, elements of denunciation can also be found before its interested parties, while access can also be inferred in the strategy of provision of public goods.

1.3. Relationship: The strategies set up a cooperative relationship with stakeholders, particularly with the governments of the three most affected states as well as with other organizations on the ground. The degree of provision of essential medical services at different stages of the epidemic was not possible without a high degree of cooperation with authorities at all levels. Cooperation occurred in various fields, but at different speeds depending on the circumstances and the interests of different governments. On the other hand, both the education and training and the participation in trials for the development of vaccines and treatments required a genuine and realistic cooperative relationship with the other actors. However, in some cases, cooperation was not possible, not because the circumstances did not demand it, but because of the lack of actors with the capacity to carry out actions on the ground.

2. The Mediterranean refugee crisis has different characteristics.

Ebola Epidemic in Western Africa (2014-2015) XXX XX X
Mediterranean Refugee Crisis (2015-2016) X XXX XX
Armed Conflict in Yemen (2015-2016) XX X XXX

The refugee crisis was the result of different events and circumstances that occurred in a variety of geographical spaces at the external borders as well as in the interior spaces of the European Union. The highest point was reached in October 2015 when the exponential increase in arrivals reached a peak of 222,800 people, which represented the same number of arrivals registered for all of 2014. The dimension that the crisis reached for public opinion was such that some media and authors did not hesitate to describe that we were in the presence of a “new exodus”.
For the year 2016 this trend is reversed, registering a fall of 2/3 of the total arrivals but a net growth in landings in Italy of more than 23,000 people. This is explained by a renewed preference for the Central Mediterranean route on the part of refugees and migrants given the restrictions lifted on the Central Mediterranean route by the EU-Turkey agreement.
In addition to the magnitude of the demands for international protection and access of migrants never before recorded at the gates of Europe in such a short period of time, the idea that the world was experiencing an unprecedented refugee crisis became widespread in world public opinion through of the media and the denunciations of the humanitarian organizations that alerted about the brutal conditions to which the migrants and refugees were subjected and the tragedies that happened daily in full view of all. The milestones of the crisis for the selected period from mid-2015 to June 2016 are presented in the following table:

MSF's intervention in the European refugee crisis had characteristics for the organization. Undoubtedly, the proposed Search and Rescue operation in the Mediterranean was different from other MSF interventions due to its characteristics. The organization's involvement in and the way it did so was distinctive due to its proximity, scale and connection to the organization's European headquarters (although it was not the first time MSF had operated in Europe). The European roots of the organization are still decisive for its operation and identity and many voices within the organization were deeply skeptical about the advisability of intervening in what is defined as "MSF's original societies" arguing that As a humanitarian organization, MSF had to remain neutral and impartial and refrain from intervening and meddling in a "very political problem".
The decision to launch ships for medical assistance to migrants and asylum seekers in the Mediterranean was the result of heated discussions within the organization. The axes on which the internal discussions revolved had to do with the moment, the form and the implications of its launch. On the one hand, it represented an operational logistical challenge like never before as, for the first time, it established a large-scale Search and Rescue mission at sea in response to a humanitarian crisis that had deeper roots in the conflicts inside Africa. and the Middle East but which claimed lives at the gates of Europe. On the other hand, the deployment of efforts to provide medical services to migrants at sea and along the access routes to Europe would reveal not only the deficiencies and negligence in care by European States, violating the international commitments for the treatment of migrants and asylum seekers, but also the harmful nature of a migration policy that sought to deter and thus block entrances to the continent.
MSF made the conscious and determined decision to exert political pressure on the institutional actors that had responsibility for the crisis through a series of strategies that combined in their forms and the opportunity to achieve the greatest possible effectiveness of raising public awareness and mobilizing societies on refugee issues and pressure EU and national decision makers to change their policies.

2.1 Authority attributes: This scenario brought to the center of the scene the deference held by MSF in the main audiences, driven by the denunciation discourse that it had developed for a long time and exercised through public statements, various publications, massive campaigns and other strategies. The denunciation had represented the other half of the organization, born out of the desire to break confidentiality agreements, which is why it was seen from the beginning as a necessary complement to medical operations.
It was not an easy decision as the political confrontation with the European authorities would be inevitable. However, the organization relied on its well-developed capabilities, particularly financial independence, to launch a variety of strategies to bring about significant political change in EU migration policies. Given the particularities of the intervention, it was not expected to have to resort to deploying strategies where access was the determinant, but its need became evident as soon as the political dispute gained strength. There were problems reaching the vulnerable population in some areas of the Mediterranean Sea and even transferring rescued people to safe ports, but the visibility of the refugee crisis was also key to unlocking the problems that arose. However, these drawbacks cannot be assimilated to a scenario of armed conflict. For its part, the medical expertise was not significant in this case since the mission contemplated primary care for a much smaller number of people than in other interventions. The added value of medical care was in the testimonies and direct evidence of the situation that migrants and asylum seekers were going through, to which MSF had access and served to leverage the denunciation discourses deployed throughout its intervention.

2.2. Strategies: The strategies that were put into play were the following:

Mediterranean Refugee Crisis (2015-2016) Information Campaign
Search and Rescue mission
Rejection of funds from the European Union and European governments
Interruption of care

All of them were designed to have a great impact on opinion and promote political change on the rules and conditions of migration to Europe. The most notorious of these was the search and rescue mission that led to MSF launching ships in the Mediterranean and gave it high visibility to its stakeholders. Some specific strategies of information campaigns such as the delivery of letters accompanied by life preservers used by migrants had a very high impact, such as the rejection of funds from the EU and European governments. This last action had a calculated and direct intention due to the low numerical representation of these financial contributions.
As it was saw in the previous scenario, the strategies combine components of different authority attributes, such as the case of access that was denounced in many pieces of information or the need for adequate medical attention that led to the action of its interruption.

2.3. Relationship: These strategies gave rise to a confrontational relationship with the European authorities that only became relative with the unavoidable need for technical coordination to navigate the Mediterranean Sea. The constant and increasingly virulent denunciation of the treatment of refugees and migrants and the furious opposition to the agreement between the EU and Turkey represented the high point of the dispute that led MSF to reject the funds and withdraw from refugee camps in Greece. The relationship did not stop being confrontational during the period under analysis and produced some accommodations within the organization as well as towards the European public that is very sensitive to the refugee crisis.
MSF's confrontational relationship with the EU manifested itself from the outset and, although there were moments of some relaxation, it never became a cooperative, beyond some specific practical needs (sending location coordinates and coordinating transfer of migrants and refugees rescued at sea).

3. Armed conflict in Yemen:

Ebola Epidemic in Western Africa (2014-2015) XXX XX X
Mediterranean Refugee Crisis (2015-2016) X XXX XX
Armed conflicto in Yemen (2015-2016) XX X XXX

The start of the bombing by the Arab coalition generated a sudden worsening of the humanitarian crisis that had been taking shape with the political instability of recent years. As the bombardments intensified, the direct casualties and the displacement of people multiplied. Access to health services became increasingly complicated due to difficulties in importing medical supplies due to the blockade and attacks on medical facilities. The impact of the crisis can be seen in the numbers of victims and internally displaced persons, which in a short time reached extraordinary dimensions. Between March 2015 and August 2016 alone, OCHA recorded a total of 40,644 victims (33,857 injured and 6,787 dead) .
The consequences for the population can also be seen in the dimension of internal displacement. According to OCHA, the number of people displaced between March 2015 and August 2016 exceeded 3 million if those who returned to their homes are counted . If we look at displacement flows for that period, we see uninterrupted growth for a little over 1 year to go from 500,000 displaced persons to more than 3 million.
In addition to the direct effect of the conflict, the aggravation of the structural problems that prevent the provision of basic services such as electricity, the lack of fuel, due to the restrictions on imports and the almost total stagnation of production, was at the center of those limitations. This directly impacted the health of the population due to the difficulties in consuming adequate calories, exacerbated by the difficulties of achieving adequate hydration in a country that lacks widespread sources of water, as well as by the increased risk of spreading diseases. infections derived from lack of hygiene.
Due to the efforts made by humanitarian actors despite the difficulties faced on the ground, by 2016, the percentage of the population with some need for humanitarian assistance was reduced to almost 70% of the population with 18.8 million people and a level of coverage that reached a little more than 54%. For this same year, it was estimated that 14.5 million people would need assistance to guarantee access to drinking water and sanitation, including 8.2 million who urgently need it.
The following graph shows the milestones of the conflict for the period from March 2015 to August June 2016:

Although MSF first deployed a medical assistance mission in 1986, its presence has remained uninterrupted in Yemen since 2007 with very diverse medical programs ranging from primary health care to maternal health programs and treatment for chronic diseases such as HIV. Due to the increase in political tensions and, anticipating a harmful effect on the Yemeni population, in 2014, MSF created an urgent response team for violent incidents and other emergencies.
At the time of the radicalization of the conflict, in 2015, the organization was able to generate acceptance in the general population and establish open channels of negotiation with the main political actors at the local and national level. Considering the experience in medical assistance in contexts of armed conflicts, the risk of losing the capital of trust achieved after so many years influenced MSF's decision not to evacuate all its international staff or cancel its programs when most of the INGOs and humanitarian agencies with a presence in Yemen made this decision based on risk assessments carried out directly or through specialized agencies and organizations. The organization's assessment was also influenced by the fact that the return to Yemen after a total evacuation would present additional problems such as the need to create a new infrastructure for security management with the difficulties for the entry of specialized personnel and materials, something that would later become evident to the other humanitarian INGOs.

3.1. Authority attributes: Armed conflicts have special characteristics that make the main challenge consist of the possibility of delivering aid. Access is the main drawback and that is where all the efforts of humanitarian INGOs go. This is how MSF understood it and arranged all its strategies aimed at delivering the necessary assistance. The organization's experience in armed conflicts and its presence in Yemen for several years gave it a differential compared to other humanitarian INGOs that reacted by evacuating all their personnel at the peak of the conflict. Much of the success in deploying access strategies was because MSF kept some of its staff assessing security risks differently based on their primary sources. In this way, the authority attribute of access became a critical measure above the others. However, medical expertise, highly valued in regions where there was no other option for the care of victims, was essential in leveraging MSF's position in the negotiations to obtain the green light to reach its patients. The fact of constituting a medical services organization is a differential in any context, but more so in a conflict in which instability and security alter any possibility of programming a mission to provide medical services. In this type of context, the availability of medical resources is another factor that determines the possibility of deploying expertise attributes and considerably improves the organization's bargaining position. Finally, with the deference of a wide variety of audiences, the denunciation speech is a delicate tool to be used in these contexts since a miscalculation can immediately imply expulsion. MSF carried out complaints, pointing out the limitations caused by the excesses and blockades imposed by the coalition led by Saudi Arabia. In this sense, MSF was careful not to openly condemn the forces that had de facto power on the ground so as not to see their aid programs altered. In any case, the organization was able to maintain the necessary balances that allowed it to deploy these discourses without affecting its missions.

3.2. Strategies: The access strategies that were analyzed in this case seek to reverse the natural asymmetry that occurs in armed conflicts between those who hold de facto power on the ground and humanitarian INGOs:

Armed Conflict in Yemen (2015-2016) Sustaining Proximity
Assertive risk management
Strengthening of the negotiating capacity
Provision of public goods
Some of these strategies go directly on the negotiating capacity and others do it indirectly. The maintenance of proximity generates a better perception by the actors on the ground as well as the provision of public goods in these contexts. Far from evacuating, MSF expanded its missions at the most critical moments of the conflict and received great acceptance from its stake/holders. But it also took advantage of its presence on the ground to make a realistic, "ethnographic" assessment of the risk to manage it appropriately and not fall into hasty and unfounded actions that did not allow him to see the opportunities that would be to expand missions or establish new windows in agreement with his counterparts. Medical expertise was also considered when undertaking the provision of public goods and the discourse when announcing and sustaining the proximity in the field that granted so many dividends in the field.
3.3. Relationship: The case of the armed conflict in Yemen shows that, in this type of context in which by nature there are problems in reaching the affected populations, a competitive relationship is configured between INGOs and their counterparts. The provision of humanitarian assistance in these contexts tends to be instrumentalized by armed groups and humanitarian INGOs must preserve the nature of their actions by opposing this use. This generates strong competition with their counterparts who see the services provided by INGOs as a source of legitimacy and a way to divert costs and reduce exposure to the populations under their responsibility. Competition manifests itself in humanitarian negotiations that are very susceptible to the unstable and changing context of armed conflicts.


Throughout this work it was intended to show the political process through which humanitarian INGOs implement strategies in the field to fulfill their missions. These strategies are based on a combination of authority attributes that are established according to the context, the characteristics of the field, and the capabilities developed by each organization. It is possible to infer that the higher the capacity development, the more likely there are to obtain positive results from the strategies deployed. The conscious and constant development of MSF capabilities and their appropriate use allowed it to be accepted to intervene in the humanitarian crises analyzed here and deploy in a combined way their authority attributes through strategies to influence their stakeholders and thus fulfill his mission.
Both the capabilities and the authority attributes are constitutive of humanitarian INGOs and their development is one of the drivers and at the same time a consequence of the organizational change through which these organizations institutionalize enough capabilities to increase their chances of fulfilling their mission. MSF, through its leaders, was making changes in its internal organization to achieve its financial independence, reach a sophisticated logistics structure, dispose of specialized medical personnel, influence the largest and most diverse audiences to amplify the impact in its denunciation actions or possess the greatest number of necessary tools to gain access to vulnerable populations. The expression of all these modifications was reflected in changes in the organizational structure such as: internationalization, bureaucratization or even decentralization. The institutionalization of these modifications provided MSF with a stronger position on the ground to fulfill its mission. Institutional learning positioned the organization as a leading humanitarian INGO in its segment and a reference for multiple audiences.
However, although some adaptive change processes and logics are expected and natural for certain stages that INGOs go through in general, there are also other factors that can influence their development such as: leadership, connectivity or brand. If the demand for change is not properly interpreted and then sustained by clear-sighted leadership, the organization will most likely lose its potential until leadership changes or expectations—and then structure—adjust to the resulting aspirations. The same with poor connectivity that does not allow taking advantage of synergies and learning from other organizations or the impact of a brand due to some specific event. The status achieved by MSF allows us to infer that the demands of the organization's natural growth imperative were identified and incorporated without significant setbacks despite the natural internal disputes such as the schism of the late 1970s that defined the permanent characteristics of the organization.
On the other hand, while an organization may have well-developed capabilities, built into its structure, it may have trouble turning that accumulated power into influence or ability to achieve results on the ground with its stakeholders. Problems can be caused by poor strategy design resulting from poor reading of the context, poor implementation, or unexpected opposition from stakeholders. To improve their chances of success, humanitarian INGOs make combined use of their authority attributes by designing strategies that contain elements of each of them. Even when there are problems, the fact that the humanitarian INGO is accepted by its stakeholders to establish relationships in each context, implies in fact a recognition and validation of its authority in the same way that other authors propose legitimation through accountability or deference.
MSF's central role in the fight against the Ebola epidemic in West Africa would not had been possible without the experience and know-how accumulated throughout its history. This role was also exacerbated by the dramatic absence of knowledge about this disease in the affected countries, but also by disinterest or negligence of other regional and international actors. A particularity of MSF's participation in the Ebola case is that it became the only actor with experience on many occasions and in various regions, , albeit with limited resources, to stop the advance of the epidemic. The expertise with which MSF came to impose conditions on the ground was also an important factor for the advocacy actions that the organization, leveraging deference in different audiences, undertook to raise awareness within the affected countries as towards international actors. With few access problems, apart from the fear and rejection of the population at times, MSF's intervention was able to be deployed to the limit of its material and human capacities to fulfill his mission.
Despite the mistrust that prevailed in the first months in some local governments such as Sierra Leone or critical disagreements, sometimes, with international organizations such as the WHO, it is possible to conclude that the logic of MSF's relationship with their stakeholders on the ground it was mostly cooperative. Each affected governments countries cooperated with the organization as soon as they understood the seriousness of the situation and the lack of alternatives to address it. Also, the organization was able to establish cooperative relationships with other organizations on the ground such as Samaritan Purse, ICRC or Red Crescent. For its part, relations with WHO moved to cooperation once an internal review of its operations revealed inconsistencies as denounced by MSF and it became clear the need to become a facilitator rather than a bureaucratic body no related to the problems. In this way, the natural position of weakness of humanitarian INGOs is not so marked, which encourages them to transfer the authority obtained to other spheres or scales, as happened with the advocacy or fundraising campaigns that were multiplied in this context. In these cases, cooperation is the most likely way of relating to other actors without ignoring, of course, that there is an opportunity for confrontation or competition, even if it does not become dominant.
The Mediterranean refugee crisis shows how humanitarian INGOs with well-developed capabilities dispose the possibility of carrying out strategies that go against their main stakeholders, in this case, European donors and the authorities that regulate activities in the countries where the Operation Centers are based. Only a rational calculation based on a good reading of the context and the future of the crisis can lead a humanitarian INGO to make these decisions without suffering serious consequences. Unlike the intervention in the Ebola epidemic, MSF's expertise was not decisive in the scenario of the Mediterranean crisis. This became clear in the internal discussions carried out to decide the relevance of launching ships into the Mediterranean Sea. The humanitarian mission to save lives, in this case, translated into avoiding shipwrecks rather than treating serious conditions. For this reason, MSF also had to deploy its knowledge and contact networks to obtain due authorizations and fulfill its mission, first in association with another organization and later by launching a ship entirely under responsibility of MSF.
MSF made the conscious and determined decision to exert political pressure on the institutional actors identified as responsible for the crisis. Appealed to a series of strategies that combined different forms and opportunity to achieve the greatest possible effectiveness of raising public awareness and mobilizing societies on refugee issues and in this way pressure EU and national decision makers to change their policies. MSF's confrontational relationship with the EU manifested itself from the outset and, although there were moments of some relaxation, it never became a cooperative during the period analyzed, beyond some specific practical needs (sending location coordinates and coordinating transfer of migrants and refugees rescued at sea).
The scenario of Yemen shows that humanitarian organizations such as MSF, which on many occasions obtain privileged access to regions blocked by other actors, can be seen as competitors by stakeholders on the ground, in particular by those who hold power de facto. In these highly unstable contexts, medical-humanitarian assistance is an asset that any actor wishes to obtain and control and to consolidate their power on the ground. The relationship established is unlikely to turn openly conflictive, at least for any length of time, as even if there is some capacity to care for the population, deficiencies in medical care on the ground immediately translate into loss of support political factions in force. This reminds us the strong tendency towards the instrumentalization and political use of humanitarian assistance in contexts of armed conflict. From the case it can be inferred that a logic of cooperation is more desirable for all the actors than confrontation. This will depend on the dynamics of the conflict which can change abruptly as we saw in Yemen.
These strategies must be considered combined with each other and supported by organizational capabilities such as economic independence or the type of mandate. In the end, without good negotiating skills, a proper network, an efficient decision-making structure, a constructive mindset, real delivery capacity, challenges will be difficult to manage, buy-in could be lost, and security will become a determinant constraint. Much of this would be enhanced if humanitarian INGOs establish as priority the conscious increase of capabilities and authority attributes to be able to fulfill their missions by deploying the best combined strategies.

A research agenda should delve into the political process in which humanitarian INGOs intervene consider the specificities of the context in which they carry out their missions but identifying regularities that add transversal knowledge to this field. This work tried to find these regularities from the analysis of a particular case supported by direct experience in the field. First challenge is to go beyond from these particularities to give these actors the due dimension in the international context considering, without doubt, the power they hold. International relations have made a great effort to incorporate these actors and recognize its political agency, but it is necessary to avoid falling into the particularities or the role of good Samaritans that they themselves promote to adequately address them. The contribution of other disciplines such as sociology or anthropology can be enriching for a complete understanding of the contexts and dynamics that are established there. Finally, it is necessary and very useful to bring humanitarian practitioners closer to the academic world because they have great contributions to make to the discipline of international relations, showing that power is also generated, administered, and distributed in various ways on the margins of major international issues causing some impact that we should know about.