MSF works in the health centre of Kintchandi, Niger , in partnership with the Ministry of Public Health

Independence and Innovation, Look beyond the Magic of Words


Xavier Crombé was Director of Studies at MSF-Crash from 2005 to 2008. He is currently working at the Research Unit on Humanitarian Stakes and Practices (UREPH) of MSF in Switzerland to publish a collective essay dealing with issues related to violence in healthcare facilities. He is also teaching humanitarian and migration issues at Sciences Po Paris.  

Though independence and innovation are both highly valued concepts, Xavier Crombé questions in this article - thanks to MSF's experiences in Niger in 2005 - the possible interactions between them.


Independence and Innovation: Absolute or Relative?

Independence and innovation have at least one thing in common – they are both highly valued concepts. This is certainly true for the field of humanitarian action but may also apply more generally to modern states and societies. Which public or private institution, political or social group would nowadays claim to oppose innovation and to cherish subordination? In an apparent paradox, however, these two nearly universal values of the “modern world” are commonly held to be under constant threat. Many states claim their right to sovereign independence and oppose interference in their internal affairs from other independence-conscious states or NGOs, while post 9/11 humanitarian NGOs have been staging an ever-increasing number of roundtable discussions, workshops and conferences around the theme “independence under threat”. In a similar vein many NGOs, in public or private, resent donors’ overwhelming demands for reports and paperwork that they think stifle innovation, while donors have been vowing to bring innovative practices to an aid community lacking adequate accountability procedures.

One important reason for this trend is that, much like concepts of “good governance”, “sustainable development” or “responsibility to protect”, independence and innovation produce an easy consensus as long as they remain abstract notions or undefined goals or principles. As soon as they start to become concrete, however, one organisation’s claim of independence is often seen by others as arrogant and self-serving opposition to coordinated action, while the groundbreaking innovation heralded by one is dismissed by another as mindless adventurism or a mere smokescreen.

If I bring this measure of relativism to the debate from the outset, it is because the possible interactions (and sometimes contradictions) between independence and innovation cannot be addressed if they are thought of as positive in and of themselves, as is so often the case. Independence from whom? and for what purpose? are questions worth asking, especially in the humanitarian field where independence is so often unquestioningly presented as a “core principle”, with little elaboration. The same applies to innovation, whether technical, scientific, organisational or some other form. Innovation from what? For what goal? For whose benefit? In fact the question might legitimately be asked whether humanitarian action is even meant to be an innovative sector? The stated purpose of development aid is to introduce innovation (whether in farming techniques, marketing practices, medical know-how or some other field) in order to bring about economic, social or political change, but humanitarian aid, strictly defined, is about alleviating suffering in times of crisis. While development offers a set of innovations for a better future, humanitarian action is about the provision of means of survival in the here and now. Hence the very different attitudes development and humanitarian NGOs have, in principle, towards independence: development professionals usually insist on “partnerships” with existing authorities, administrations and “communities”; humanitarians, on the other hand, see themselves as filling voids and acting as temporary substitutes for local institutions in disarray and for uncaring, reluctant or incapacitated authorities, whether legitimate or de facto.

Lessons from Niger

The following section is derived from various contributions in Xavier Crombe & Jean-Herve Jezequel (ed.), Niger 2005, une catastrophe si naturelle, Paris Karthala/MSF, 2007 (English version forthcoming 2008).

This very distinction lies at the heart of the controversies that divided the various aid-related institutions in Niger in the course of the 2005 food crisis. To development advocates, “emergency” humanitarian agencies were guilty of arrogance, disrespect for the sovereignty of the Niger government and ignorance of the local context. They emphasized the need for long-term policies and stable market practices to fix what, to them, was not an emergency but a chronic crisis. As a result they opposed emergency responses, especially free food distributions. They argued that this failed to address the structural causes of the problem and would jeopardize efforts made over the previous twenty years to foster sustained development, instead trapping Niger’s rural communities in a vicious circle of dependence. Humanitarian “emergency” NGOs such as MSF counter- attacked by arguing that the ongoing food crisis was evidence of the failure of past policies based on market deregulation to ensure food security for the poorest families. They further criticized development policy-makers for turning a blind eye to the present suffering of the population, in particular ignoring the deaths of tens of thousands of malnourished children, all in the name of food security improvements and individual producers’ autonomy at some distant point in the future.

This protracted debate along the all-too-familiar lines of emergency vs. development aid actually served to obscure the more complex reasoning and interactions that shaped the 2005 crisis in Niger. Innovation and independence had a role in these, but not necessarily in the ways that might have been expected.

To all its stakeholders the food security system put in place in Niger at the end of the 1990s was highly innovative. It relied for data collection on state-of-the-art technology for monitoring food crops, including satellite images provided by NASA, and was meant to break away from former bureaucratic control by emphasizing market deregulation and monitoring. It was also innovative in that its “core principles” were partnership and consensus among its stakeholders (the government of Niger, the European Union, several bilateral donor countries and the World Food Programme). These partners in the new approach to food security also had independence in mind - Niger’s independence from food aid, although donors were responsible for funding grain reserves to cover possible shortages before that ultimate goal could be achieved.

Contrary to an accusation commonly made by development agencies, not all the organizations ringing the emergency bell in 2005 were newcomers in Niger. Nor were they necessarily emergency-oriented in their programming prior to that year. Following a series of interventions in the country since the mid 1980s addressing either nutritional needs or epidemics, MSF France had settled down in the Maradi region in early 2002 and embarked on a medium-term nutritional programme. The driver behind this decision, quite debated at the time, was innovation, both scientific and organisational. The scientific (and technical) innovation was Plumpy’nut, a ready-to- use therapeutic food (RUTF) available in a sachet and the result of progress in nutritional research that had identified the cause of malnutrition as micronutrient deficiency rather than lack of protein, a long-time creed of nutritionists. Plumpy’nut was the product of cooperation between the nutrition department of the French public research unit IRD (Institute for Development Research) and a private small-scale food company, Nutriset. It was not MSF but the nutritional consultancy Valid International that first saw the potential of RUTF. Its members developed a new protocol called Community Therapeutic Care (CTC) which was designed to increase the reach of existing feeding centres by allowing most severely malnourished children to be treated at home with the use of RUTF. It was this combination of innovations that convinced two members of MSF, a nutritionist from the medical-technical department and the medical doctor heading the emergency department, to try and implement this new protocol in Niger in 2002.

The programme they established was about filling a void: with the attention and funding of donors focused on preventing food crises through crop monitoring and food market liberalisation, therapeutic treatment of severe malnutrition was no longer available in Niger’s health system. In addition, Niger was a stable country in which progressive experimentation with this new approach was feasible; its results would also be useful for more “classical” emergency situations in war zones. MSF was soon running a private therapeutic centre in Maradi, financed with its own private funding. Yet, independence in this case bordered on isolation - while not opposed to it, neither Niger’s Ministry of Health nor the aid community showed any interest in this nutritional project. In contrast, the MSF team’s efforts to have a new and more effective protocol for malaria treatment registered at national level met with strong resistance from the medical authorities, who saw it as impinging on the state’s sovereignty. Within MSF, the Niger nutritional programme also received little attention or support. Niger’s peaceful context meant that it was not a priority for the MSF operations department while many doctors, both at headquarters and field level, remained sceptical about a programme that reduced medical supervision of the treatment of children with severe conditions. To overcome this internal resistance external expertise (a nutritionist, a psycho- anthropologist…) was sought and dispatched to the field.

In 2004 the programme started to show impressive results, with 10,000 children treated, more than 80% of them cured. It also began to receive increasing interest: the WFP representative in Niamey was willing for the agency to reinvest in severe malnutrition in Niger and to purchase Plumpy’nut from the local production MSF had helped to set up in an attempt to lower its cost. This encouraged MSF to push for donors and medical authorities to recognise the scale of malnutrition in Niger and to include adoption of the innovative therapeutic protocol in their strategic objectives for 2005. Indeed central to MSF’s operational choices, public statements and overall role in the 2005 food crisis in Niger was the goal, set prior to the crisis, of diffusing this tested innovation for the treatment of severe malnutrition. The controversies that subsequently erupted reflected resistance from donors and local authorities to this process, notably because the images of starving children filmed in MSF feeding centres were used as evidence of the failing of the food security apparatus and were undermining the culture of consensus upon which it was built. The MSF programme was marked by both independence and dependence. Financial independence allowed the organisation to carry out its nutritional program on an unprecedented scale, with 40,000 children treated in 2005. At the same time MSF remained dependent on a number of other factors: on media coverage of the food crisis, which contributed to a blurring of its message; on the capacity of other NGOs to adapt to the situation; on the ambivalent position of WFP, torn between its role as donor representative in the food security system and that of emergency food agency; on political infighting within the Niger government; and on local understanding of the crisis and the belated international response to it.

What did the food crisis and the way it was reported do for the diffusion of the nutritional innovation promoted by MSF? The use of RUTF for severe malnutrition was registered as the national protocol in Niger; nutritional surveys, rare prior to the crisis, are now routinely undertaken by UN agencies and NGOs to monitor the situation; and therapeutic feeding centres funded by international donors have flourished. At the global level, WHO, UNICEF and WFP published a joint press communiqué calling for the international community to mobilise to treat severe malnutrition worldwide and recommending the use of RUTF combined with the CTC method. The Niger crisis certainly had an accelerating effect on the renewed interest of international health institutions in a more medical approach to malnutrition, although this was also part of a more general trend following a decade of exclusive public health focus on infectious diseases. Finally, it is also worth noting that this process of adoption, implementation and diffusion of innovation by MSF in Niger and the dynamics of the 2005 crisis have resulted in important changes in MSF’s outlook. MSF’s historical approach to nutrition was limited to emergency situations; having only reluctantly engaged in a medium-term programme in Niger’s context of chronic malnutrition, the organisation has now launched an international campaign to promote increased use of ready-to-use food not only to treat but also to prevent malnutrition in endemic areas.

Social and Political Processes

As this lengthy account of MSF’s experience with nutrition in Niger has attempted to show, there is no simple equation between independence and innovation. Interdependence is more often than not the modus operandi of humanitarian NGOs in the field. It is not their invocation of a ‘core principle’, but their readiness to oppose, when necessary, the culture of consensus, allied to the weight and credibility their voice has acquired through years of effective relief action, that enables them (albeit not always) to avoid being tied to the agendas of others. Historically the humanitarian sector has developed through a series of innovations, usually referred to as professionalisation. This process began in the 1980s, when NGOs were faced with the daunting task of meeting the needs of populations living in refugee camps. The purpose of professionalisation was to develop the means of delivering effective assistance to large groups of people, but it also increased humanitarian agencies’ autonomy of decision and action. In the Cold War context, however, aid provided by primarily Western NGOs was hardly perceived as independent.

Medical kits, new logistics tools and water engineering are the most obvious innovations of this period. But professionalisation subsequently incorporated other forms of innovation, including some borrowed from the commercial and other sectors like new means of communication, standardized recruitment techniques and accounting standards. With consultants and employees from these sectors being sought by NGOs to bring new expertise to humanitarian action, this process of professionalisation reflects a more general evolution in the concept of “professionalism” in Western societies. Increasingly professionalized NGOs in turn witnessed a change in their working environment, one in which they had played an important part, willingly or not. The successive reforms of USAID and the creation of DFID in the UK reflected the way in which donors were adapting to the evolution of NGOs. This process was accompanied by new requirements and channels of control, in much the same way as local authorities and communities in the field were adjusting and increasing their demands towards better resourced aid organizations.

As the work of sociologists and anthropologists showsFor a useful synthesis, see Jean-Pierre Olivier de Sardan, Anthropology and Development, Understanding Contemporary Social Change, London, Zed Books, 2005, innovation and its diffusion can only be understood with reference to the societal context in which they occur. Existing political, economic or symbolic conflicts largely determine the acceptance or rejection of a given innovation, as any innovation inevitably serves some interests while running counter to others. As the Niger case illustrates, this may be the case within a single NGO, between the various departments, professions and individuals of which it is made up, in the broader aid community or in the local societies receiving international assistance. The political stakes may of course differ depending on the aim of innovation - to raise “humanitarian standards”, change public health policies or improve the living conditions of local communities, for example - but these various objectives and the type of resistance they may encounter are often interconnected. Hence, questioning the links between independence and innovation in humanitarian action is to reflect upon the many unexpected ways in which our own evolution has changed the social and political environment in which we now work, for better or for worse.


To cite this content :
Xavier Crombé, “Independence and Innovation, Look beyond the Magic of Words”, 1 mars 2008, URL :

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