Jean-Hervé Jézéquel, Paris, MSF-Crash

The passage from a time of war to post-conflict raises the question of the changing face of the aid mechanisms set up by MSF and the attitudes that lend legitimacy to its operations. Times of war, often thought of as being the core activity of MSF teams, are also times of certainty and clarity: war is viewed as being the most legitimate cause for intervention by MSF. Once war ceases, the certainty evaporates: as combat comes to a halt, so does the initial motivation for the deployment of MSF teams: to provide assistance to populations who find themselves victims of a conflict.
How do different MSF sections navigate the shift from war to post-war? How can they best (re)define programmes and choose beneficiaries in contexts where the primary driver for deployment has disappeared? How, and for what reasons, can they make the choice whether to stay or go? How do MSF sections adapt to a new environment characterised by the deployment of a more concerted and, more importantly, a more ambitious aid effort? This case study looks at Liberia and attempts to answer these questions by tracking the way that the various MSF sections adapted to the challenges of the post-war context over the five-year period following the cessation of hostilities.Liberia was chosen for several reasons: we wanted to look at a country where the end of war was very clear to all actors, not a hybrid situation between war and peace. Liberia is also a country were MSF’s presence has been both widespread and relatively lengthy; we wanted to examine the influence, or lack of it, of MSF’s presence and history in the country on the reconfiguration of its post-war operations; finally, the author’s familiarity with the Liberian context also played a part in determining which country to study.
In the Liberian case, these reconfigurations occurred primarily against a background of profound changes in the external environment, and a working space progressively saturated by other actors and viewpoints tied in with Reconstruction, an imperative that weighed more and more heavily on intervention possibilities. The way in which the MSF sections reacted to this environment and its specific restrictions depended on a series of dynamics specific to each section. Different sections interpreted the post-conflict notion in different ways that reflected their own history and perception of MSF’s mandate and missions, but were also influenced by more short-term factors: important subjects at the time, such as surgical provision and programmes for victims of sexual violence, balances of power at head office, etc.
After setting out the elements essential to an understanding of the Liberian context (and noting the extent to which it represented a testing ground for managing post-conflict situations), we will then describe and compare the operational choices made by the three MSF sections in Liberia (MSF France, MSF Belgium and MSF Switzerland). Whilst underlining the differences between the choices made, we will show that the reconfiguration of each section’s operations was the upshot of a fairly consensual and shared vision of the challenges of post-conflict Liberia: each section questioned what its role in the reconstruction of the country could be, even though each in turn came up with a different answer. This attitude, which reduces the post-conflict notion to the challenges of transition and reconstruction, was greatly influenced by the interpretations produced by actors involved in post-conflict management. In the final section, we suggest that a more critical position vis- à-vis this mindset and a more politically-focused analysis of the post-conflict context could radically alter the way that MSF sections perceive the humanitarian challenges of post-Taylor Liberia.

1. THE LIBERIAN CONTEXT: THE END OF WAR AND INTERNATIONAL POST-CONFLICT MANAGEMENT

1.1. A SHORT HISTORY OF THE POST-CONFLICT PHASE

War erupted in Liberia in December 1989 when a small group of armed men under Charles Taylor seized several towns in Nimba, in the north of the country. The country was no stranger to armed conflict; the 1980s had already witnessed their share of fighting, including the rice riots and police violence in Monrovia in 1979, Samuel Doe’s bloody 1980 coup, and the widespread repression in Nimba after Thomas Quiwonkpa’s failed coup in 1985. A longer study of the country’s policing practices would reveal the preponderance of forms of physical violence during “times of peace.”Certain forms of torture used by militia during the war explicitly mimicked abuses employed by the Liberian Frontier Force during peacetime to collect taxes and duty (Interview with a Liberian ACF employee, Kolahun, January 2007).Nonetheless, 1989 did mark a step change in terms of levels of mass violence: with the rapid multiplication of rebel movements and self-defence groups, Liberia sank into civil war (Ellis, 1999). Liberia came to symbolise the failed, or shadow, State that began to emerge in Africa during the 1990s.The idea of a shadow State was popularised by William Reno (Warlord Politics and African States, 1998), who applied it to Sierra Leone and Liberia (as well as Congo, Somalia and Nigeria). There is, in fact, a disparity between Reno’s concept of the shadow State and the superficial way the term it is used by the press, NGOs and other experts. These groups feel that a shadow State denotes a situation where the State has collapsed, leaving a few official trappings but with nothing to back them up, mere empty shells (see for instance J. P. Pham, Liberia. Portrait of a Failed State, 2004). Reno, on the other hand, felt that a shadow State represented a new system of patronage that emerged in a number of African countries with the end of the Cold War. The governing elites encouraged the growth of informal markets to offset the decline in central authority. The State, far from disappearing, was regrouping in a privatised form that generally embraced illegal activities and organized crime. Despite criticism of the notion of the failed State by some academics (Bayart, Ellis, Reno), it was an idea that took root during the years 1990-2000, in particular within networks linked to the “new liberal interventionism” (to adopt a phrase used by R. Banégas and R. Marchal in Politique africaine, issue 98, 2005). During the 2000s, it eased the path, and provided legitimacy for, intervention by the international community as it got involved in reconstructing failed States in the name of a durable peace.
It is interesting to note the extent to which humanitarian aid was mobilised as part of this international management of the war. During the final three years of the conflict (2001-2003), humanitarian aid became party first to the containment then, following September 2001, the eviction of the Taylor regime. It was an era that also saw the failed State notion steadily replaced by that of the rogue State (Jézéquel, in Weissman, A l’ombre des guerres justes [In the Shadow of Just Wars], 2003): the Taylor regime was frequently described as the primary motor for violence in the sub-region, accused of ties to terrorist networks via so-called blood diamonds. Rogue State was more than just a label, like Failed State. It was a description that both announced and justified a process of financial disengagement of the international community from Liberia. For there could no longer be any question of making resources available to a State that diverted them in order to wage war or to finance international terrorists and criminal networks. There was therefore a sharp fall-off in humanitarian aid coming into the country as of the early 2000s (with a parallel increase in resources allocated to neighbouring Sierra Leone and Guinea). To this cutback was added a UN embargo on trade in arms and the country’s main resources (wood and diamonds). From the late 1990s until the fall of the Taylor regime, MSF teams were working in a context where the UN was providing the bare minimum and other international NGOs, cut off from funds, were very thin on the ground.
The context for the intervention was by no means easy (security for the teams, militia instrumentalisation of aid) but it was very rewarding (venturing where others did not go, a sense of filling a true medical need). Aside from the safety aspects, the restrictions on MSF’s operations were relatively few: within a humanitarian space left empty by many actors, MSF was fairly free to undertake its operations as it saw fit. Negotiations with the Liberian authorities, especially representatives from the health ministry, were not necessarily straightforward, but MSF was seen as a trusted partner and it maintained regular contact with top health officials.To the extent that, at times, MSF had a reputation for supporting the Taylor regime.
The situation was reversed after 2003: the return of a large-scale UN and donor presence, with an impressive number of NGOs following in their wake, profoundly altered the context of the intervention. At the political level, the institutional and official expression of the Liberian government progressively superseded the former shadow State (in the sense meant by Reno). It became harder to stand out in a space now crawling with white 4x4s. It became problematic to independently decide on a policy within a space now featuring several coordination structures, and where new framework planning policies were regularly published.The idea of planning and coordinating interventions did not completely disappear during the war, but this type of approach increased massively following the fall of Taylor.

1.2. POST-TAYLOR LIBERIA: AN INTERNATIONAL TESTING ROUND FOR STATE RECONSTRUCTION POLICIES

August 2003 was the tipping point when the conflict entered its final phase: with the arrival of the first contingent of Nigerian ECOMIL forces,As the armed wing of ECOWAS (Economic Community of West African States), west African troops serving under the ECOMIL banner were deployed to Monrovia immediately after Taylor went into exile in August 2003. Some of these troops were later incorporated in the UN peace-keeping mission (UNMIL), which took over in October 2003.Charles Taylor handed power over to Vice-president Moses Blah and left to go into exile in Nigeria. The temporary ceasefire was followed on 18 August by a peace agreement signed in Ghana between the various armed factions. They agreed to form an interim government led by Gyude Bryant, a Liberian businessman acceptable to the various armed groups and the international community. On 19 Septem- ber, the UN Security Council decided on the creation of a UN mission for Liberia (UNMIL), which would eventually number up to 15,000 soldiers (at the time it was the largest ever UN peace-keeping mission, for a country with a population of just 3.5 million). Elections were scheduled for October 2005. In the meantime, the country was to be run by the National Transitional Government of Liberia (NTGL) under Gyude Bryant and with the support of (or, according to some, under the control of) the international community.
Unobtrusive under Taylor, international institutions poured into Liberia as of the second half of 2003. The institutions wanted to cooperate with the interim government to help address the wounds left by a long civil conflict as well as, in the short term, deal with the consequences of the past few months of fighting, which had been particularly hard on the Liberian people. The reputation for corruption that the transition government soon earned served to curb the desire to cooperate with the Liberian authorities, until the election of Ellen Johnson-Sirleaf in late 2005.

Immediate post-war humanitarian challenges (2003-2004)
There were three major sets of problems that faced aid professionals in the post-war situation: the amount of destruction, the situation of the displaced and refugees, and the particular problem of Monrovia.
During the final phase of the Liberian civil war (1999-2003), entire regions of Liberia remained beyond the reach of international aid for months if not years. This was particularly true of Lofa, a region lying on the border with Guinea and Sierra Leone in the north west of the country, where no organisation had been able to do any meaningful work since fighting flared up again in late 1999/early 2000. Witnesses and specialists both stress the high levels of destruction experienced during these final months of the conflict. According to Danny Hoffman, a specialist on armed groups in the Mano River, the final offensives undertaken by Liberians United for Reconciliation and Democracy (LURD) between 2001 and 2003 were characterised by a scorched earth policy not before seen in the Liberian conflict. It was a strategy directly rooted in combatants’ perceptions of the aid system: the greater the destruction and atrocities, the more the aid would flow and the fighters would be able to reap its benefits once the fighting came to an end. Hoffman also draws a direct link between warfare strategies, humanitarian aid and post-war dynamics. It was almost as if the armed groups themselves had taken on board the ERD continuum (Emergency/Rehabilitation/Development). Whatever the merits of Hoffman’s analysis,In my opinion, Hoffman’s analysis underestimates the diversity of the dynamics the rebels had to deal with. For example, it’s clear that LURD commanders in Monrovia attempted to restrain the troops—with limited success—in order to limit the amount of pillage and destruction that occurred. They were trying to give the LURD a respectable image—tolerable might be a better word—and to avoid the international intervention that Taylor was calling for to bolster his chances of retaining power.areas most-affected by LURD (Lofa and, to a lesser degree, northern Nimba) were soon to be the places that received the most assistance.
Post-Taylor Liberia was also beset by the problem of populations in flight. The UN estimated that when the war ended almost 500,000 Liberians were internally displaced (mainly in the camps at Bong, in the centre of the country, and around Monrovia) and a further 340,000 were refugees in neighbouring countries of the sub-region (primarily Guinea, Ivory Coast, Sierra Leone and Ghana). A total of almost one Liberian in every four had to move because of the conflict. As soon as the fighting came to end, the question arose of their repatriation or resettlement in their home regions. Finally, there is the special case of Monrovia. During the first months of hostilities, a mass of displaced people flooded into the city fleeing the advancing fighting. In addition to the problem of refugees living in a belt of camps surrounding the city was the issue of the squatters who crammed into every ‘available’ building in town. It was impossible to count Monrovia’s population (unlike the campdwellers). So, guesses were made: there were an estimated 1 to 1.5 million people living in Greater Monrovia (the city and its outlying regions), i.e. almost one Liberian in 3.

The 2005 presidential elections were won by the international community’s preferred candidate, Ellen Johnson-Sirleaf, a Harvard-educated economist and former UNDP official. The government she installed in 2006 comprised politicians and technocrats, many of whom had experience of the US or international bodies. Johnson-Sirleaf removed the former militia members who had been a feature of the transition government.
Liberia became a vast experiment, where the UN, World Bank and major donors (ECHO, USAID) tested out techniques for State reconstruction. US and European technical advisors, some of them only recently graduated, came to “assist” the various ministries. Not just the institutions, but the whole political, economic and social order needed rebuilding, as they were thought to have been totally “destructured” after thirteen years of fighting. An agenda on this scale required setting up systems for coordinating the aid actors amongst themselves, and with the Liberian authorities. The two main post-war priorities of the time were the disarmament and reintegration of former fighters (and more generally the restructuring of the security forces, the number one priority for government and international actors alike), and the return of refugees and displaced populations to their home regions.
It is helpful to take a longer view of the focus on political re-engineering in post-Taylor Liberia. Mark Duffield has shown how much the 1990s served to crystallise problems of war and security in a development context (Duffield 2007). This issue was clearly relevant to Liberia, where the Taylor regime was not only accused of fomenting regional unrest (Guinea, Sierra Leone, Ivory Coast) but of using blood diamonds to help finance terrorist networks. The aim of Liberian reconstruction policies was to do away with this two-pronged regional and global threat. It is instructive to note how the messages coming from the new Liberian regime dovetailed into this security dimension. During her first trips as president, Johnson-Sirleaf discussed a political vision that she referred to as the New Liberia, a country built upon new foundations and making a clean break from the old divisions between natives and descendants of the African-American colonisers. One of the central components of her message was security, which Johnson-Sirleaf stated would be her topmost priority: security was what the country needed above all. Today, we might legitimately wonder whether Johnson-Sirleaf was expressing the wishes of the Liberian people—or of the international community.
However, it would be a mistake to overestimate the coherence of this “international testing ground”. A number of mechanisms were put in place with agendas that were more competing than complementary. Starting in 2005, the UN experimented with reforms to the clusters“The cluster approach was introduced as part of humanitarian reform in 2005. It seeks to make humanitarian assistance more effective by introducing a system of sectoral coordination with designated lead organizations.” (IASC Cluster Approach Evaluation, April 2010).that supported its integrated missions“An Integrated Mission is an instrument with which the UN seeks to help countries in the transition from war to lasting peace, or to address a similarly complex situation that requires a system-wide UN response, through subsuming actors and approaches within an overall political-strategic crisis management framework.” (Report on Integrated Missions, UN ECHA Core Group, May 2005).—which in the Liberian case were placed under the military command of UNMIL. Working in this way caused some tensions with the NGO community as well as civilian branches of the UN, as is evidenced by the eviction of the OCHA.Within the framework of an integrated mission, the role of coordinating humanitarian assistance filled by UNMIL (Humanitarian Coordination Section-HCS) provoked endless tensions with the OCHA mission in Liberia. The OCHA is a UN agency that is generally put in charge of coordinating humanitarian efforts. In Liberia, it was deprived of its main raison d’être and forced to leave the country in November 2004. Many NGOs expressed disappointment when it left, taking the view that it robbed the country of an “independent” coordination body. A number of subsequent OCHA reports were critical of the lack of experience in coordination of the HCS staff, blaming them for a number of failures in operations to resettle refugees and displaced persons (for example: OCHA Follow-up Mission to Liberia, May 2005).The World Bank and the main donors set up specific forums within which they developed their own visions of reconstruction, and which they encouraged the NGOs to join.

1.3. RECONSTRUCTION: AN OMNIPRESENT ISSUE

The post-war period saw the convergence of a number of viewpoints, all seeking to stress the legitimacy of international involvement in Liberia: the necessity of rebuilding a failed State, the ERD continuum and the establishment of a proper bureaucratic aid system within the framework of the cluster reforms, and the New Liberia. The mechanisms that then emerged changed the working conditions for humanitarian actors, especially those that had been operating in Liberia before the new arrivals. Some aid operations were ruled out once it became clear that they did not fit with the main donors’ political priorities: NGOs were unable to find funds if their projects did not sit within the political orientations or zones defined as being priorities (underserved counties, i.e. the rural interior). For example, it was hard to find funds for providing nutritional support in urban areas, whereas these were available for work in the countryside. However, studies conducted by Action Against Hunger on a number of occasions pointed to child malnutrition being more problematic in areas of Monrovia than in the interior. Furthermore, rightly or wrongly, messages concerning the need to coordinate aid were perceived as being attempts to force NGOs to accept an agenda driven by State actors and international institutions (UN and/or financial). NGOs like MSF, which took the decision to remain on the margins of the coordination process (adopting observer status at most) and which, depending on the particular section, had objectives that differed to varying degrees from those of the reconstruction process, were nonetheless unable to fully escape these pressures. Teams were confronted by the omnipresent emphasis on reconstruction and by intrusive arrangements that, although far from all embracing, did nonetheless tend to reduce the freedom of manoeuvre available to humanitarian actors. These arrangements were not necessarily new, and similar arrangements applied in time of war, but they seemed to be harder to resist or avoid in a post-war environment. They appeared more coherent and entrenched in a post-conflict climate, strengthened by the reinvigorated legitimacy of a peacetime State and its shared conviction of the importance of reconstruction.

2. MSF’S OPERATIONAL PRACTICES IN LIBERIA (2003-2008)

The following pages are devoted to describing operations run by three MSF sections (France, Belgium and Switzerland) in Liberia between 2003 and 2008. We also distinguish between the periods before and after the election of Ellen Johnson-Sirleaf.

2.1. WAR IS OVER—BUT THE FIGHTING GOES ON (2003-2005)

In Liberia, the immediate post-war period was at first thought of as a time of instability, neither peace nor war. The 2003-2004 period was indeed a time of deep political uncertainty: how troublesome would Charles Taylor prove to be from his Nigerian exile? Would the leaders of the former rebel groups play the peace and reconciliation game? Would they prove strong enough to contain the frustrations of their former fighters?
On the one hand, the genuine political advances were cause for optimism: former fighters were turning in their weapons and refugees and displaced people were returning, notwithstanding a few local incidents and delays. On the other hand, the regular outbreaks of violence encouraged actors operating in Liberia to be cautious (attack on the UN office in Gbarngba in 2004, violent demonstrations at the Liberia University campus and the main markets in Monrovia, an upsurge in urban crime, etc.). It is important to remember this uncertain atmosphere when judging MSF’s operations at the time: it is only in retrospect that 2003 came to herald the start of the post-conflict phase. Only looking back is it clear that the war was over, and actors at the time did not have the benefit of hindsight. This is all the more true when you consider that Liberia had already lived through a failed post-war period: after the peace agreements were signed and Charles Taylor elected president in 1997, the country was officially declared to be in a state of “post-conflict”. Two years later, in late 1999, war broke out again in the north of the country, forcing tens of thousands to flee homes they had only recently returned to.
The post-war phase was initially approached by the MSF sections with analysis mechanisms similar to those that prevailed during the conflict. Indeed, at first the various sections developed operations that were fairly similar to each other: a presence in Monrovia working in primary and secondary care structures, and activities in the interior in zones where fighting had occurred or that were still in the hands of factions that had yet to disarm.
This way of thinking was a hangover from the war, and its influence was felt strongly during the first post-conflict years in the way that the MSF sections dealt with their relations with the UN and donors. The question of independence from the UNMIL military force was also a concern shared by all the sections; it was an issue particularly relevant to deployments beyond Monrovia. The prospect of a possible renewed outbreak of fighting caused MSF to keep its distance from UNMIL, to the extent that, like the French section in Lofa, it refused to make use of its medical evacuation capacities. The teams were concerned not to be thought of as connected to the international forces, which would compromise their access on the ground were fighting to break out again.
In more general terms, the MSF sections stayed away from, or at the margins of, the coordination forums set up by/for aid actors (they joined most often in the role of observers, a position that they would fight to retain in the coming years, especially during the cluster reform process). In May 2006, the mission heads of the various MSF sections present in Liberia signed a joint declaration stating that MSF would not join any clusters,On the subject of clusters, see footnote 83.but that it would seek observer status.
Yet whilst aid to Liberia tripled year-on-year (from US$14 million in 2002, to US$50 million in 2003, to US$147 million in 2004),Sources: reliefweb.org.the three MSF sections examined here accepted ECHO funding that comprised a far from negligible portion of their budgets (40% of the MSF-B project to support primary care structures in Monrovia in 2006, up to 2/3 for Benson Hospital). The part played by European funding in the overall mission budgets was debated internally, especially within the French section.The reasons for this included the fact that ECHO repeatedly requested MSF-F to increase visibility of ECHO’s financial contribution to its projects. The question of the share of ECHO-derived funding for the various MSF sections was also raised by the Spanish section in relation to the Benson project in 2007 (Field visit report Liberia, MSF-Spain, 15-22 January 2006).Some feared that MSF would be instrumentalised to push the European agency’s political agenda. Ironically though, our interviews with ECHO managers suggest that the opposite applied; a number of incoming ECHO managers were former MSF-B staffers. Indeed, ECHO’s emphasis on secondary care in Liberia differed from the European agency’s usual approach.Interview with ECHO Monrovia representative, February 2009.Opinions on this are divided, but some claim to identify in ECHO’s priorities the influence of operational choices made by MSF, which was heavily involved with Monrovia’s hospitals.

2.1.1. MSF-FRANCE: “A WISE MAN IN TIMES OF PEACE PREPARES FOR WAR”

The French section had a presence in Liberia from 1990. With the exception of a few days during the summer of 2003 when it was evacuated, it had provided a more or less continuous presence in Monrovia, even during periods of fighting. The head office coordination team had many years experience of the country, which had already know successive phases of calm and violence (especially the two years of “peace” that followed Taylor’s 1997 election).
In 2003-2004, the coordination team felt that the peace was fragile and the risks of renewed violence all too real: “We didn’t know what was going to happen, but our political analysis tended to indicate that a renewed outbreak of fighting in the sub-region was possible”.Interview with a member of the head office coordination team. Of the three projects that the section was managing post-2003, two were new openings (Mamba Point Hospital and the Lofa project) set up in anticipation of the possibility of renewed fighting. Only the Lofa project was the continuation of a previous action (the Bong displaced persons camp). Within a context explicitly referred to as “artificial peace,In the words of a member of the Paris coordination team.specific post-conflict problems had yet to arise.

Openings: the Mamba Point Hospital (MPH) and Lofa projects

The opening of the MPH project, a private 140-bedThis number varied between 2003 and 2007. The number given here is the number of beds during the first year of operation (specifically, in June 2004, after the MPH 2004 half-yearly medical report).hospital wholly managed by MSF, is a good illustration of the way that a project is put together, being a combination of an analysis of the context and the internal dynamics of the Paris head office. The idea of a project to open a referral hospital in Monrovia dated back to the early 2000s.The information referred to here came from interviews with former Paris coordination team heads and ex-Heads of Mission.Some of the teams felt at the time that Monrovia’s health system was in a catastrophic state, especially regarding secondary care. When the LURD assault on Monrovia started to become a reality in 2000-2001, some started to plan for possible fighting close to, or within, the capital itself. Consequently, a project for an urban hospital was sent to the operations department. In the end, the project was rejected for two main reasons: firstly, head office decided to emphasize mobility and agility so that MSF teams could follow the fighting and displaced people, rather than undertake a static, and costly, programme in Monrovia; secondly, the idea of investing in a hospital structure was considered to be too demanding, too complex and not suitable owing to the volatility of the situation. The outbreak of fighting in the summer of 2003 heralded a renewed interest in the project.
During the siege of Monrovia (June to August 2003), MSF teams were isolated within the Mamba Point neighbourhood, and were treating injuries from gunshots and mortar fragments. Lacking an appropriate structure, the expatriates’ house was transformed into a makeshift hospital that performed over 1,000 operations during the summer of 2003. Once the fighting ceased and Charles Taylor had left, another project for a city hospital was submitted to the Paris coordination team.
The request to open a new structure was based on two factors. First, Monrovia’s flagrant lack of secondary structures and in-patient facilities. Second, and perhaps more importantly, the desk team felt that the country’s situation remained volatile: faced with the prospect of renewed fighting and violence, the team wanted to be able to call on a structure suited to caring for the wounded, and was reluctant to repeat summer 2003’s experience of the “make-do emergency.”Interview with MSF-F Liberia Desk, 2008.
The project gained political backing from the operations division and technical support from the medical department, which was increasingly interested in surgical provision.Interview with MSF-F Liberia Desk, 2009.A project for a private hospital in an urban area was a relatively novel idea. It was soon to take its place amongst other similar schemes, such as in Port au Prince, Haiti, and Port Harcourt, Nigeria.
The MSF hospital opened in Mamba Point, the area where the embassies were located, in November 2003. Unlike the hospital project opened by MSF-B at Redemption Hospital in 1999, which was run jointly with Liberian Ministry of Health backing and staff, the MPH was entirely private and was run under the entire responsibility of the French section. In this way, a project designed at the height of the fighting came into being once combat had ceased.
However, the exact nature of this hospital project remained ambiguous. It was originally designed to provide emergency treatment. But, in post-Taylor Liberia, what qualified exactly as an emergency? Some felt that this meant providing care to victims of “armed” or “collective” violence. Yet for five years, the hospital only ever had to treat two waves of patients injured in outbreaks of collective violence (the riots in December 2003 and October 2004). The MPH was tied in to a Liberian conflict that was thought to be about to break out again...but never did. Others therefore felt that the definition of what constituted an emergency should be extended to include a raft of acute cases that required immediate care.“Mamba Point Hospital is an emergency hospital…but… what is an emergency??? It is very difficult to define this word… In Liberia there are “just hospitals”, nobody knows about emergency hospitals, for that reason we decided to start to talk about acute cases… “ (End of mission report, MPH project coordinator, July 2004).Patients in this category were hardly in short supply, given the state of the Liberian capital’s health system and the dearth of secondary care structures. Yet the character of the MPH was changing and it progressively became a general hospital, raising the question of what exactly were the limits to the types of care on offer?After five months in operation, the MPH project coordinator felt that: “It is likely that the hospital will become more of a general hospital than an emergency hospital, as it was originally conceived.” (MPH project coordinator report, April 2004).This also raised the question of MSF’s role in a context free of the conflict and collective violence that were then felt to be its core activity. The MPH, designed in wartime and established post-war to treat victims of collective violence, was turning into a “transition hospital” that had to make up for the shortfall in secondary care provision in Monrovia until such time as the health system could be re-established.

MSF-F also opened another project, in the region of Lofa, after combat ceased: MSF ran two small structures offering out-patient and in-patient care (OPD/IPD); these structures were located within health ministry premises at Kolahun, and in private premises at Foya. The medical services were provided to people living locally: families of former fighters, those unable to flee during the war, and returnees, whose numbers grew little-by-little until disarmament.Kolahun was one of the last towns in Liberia to be disarmed, in 2005.MSF-F wanted to deploy to zones long deserted by aid organisations since the heavy fighting started (Lofa was almost inaccessible from late 1999/early 2000 to late 2003). The MSF-F teams wanted to go “where others don’t go, stopped going to, or haven’t got to yet.” After the fall of the Taylor regime, a growing number of NGOs and UN agencies started to (re)deploy to Liberia. The situation was in contrast to the relative vacuum in which MSF teams operated during the early 2000s. Initially, these organisations remained in Monrovia and a handful of areas secured by UNMIL (primarily the route to the camps at Bong and the town of Gbarngba). The rest of the country lacked outside aid… and often any remaining population.The relative vacuum in of Lofa initially led to debate within MSF about the value in deploying to such areas. At first, the worry was that there would not be enough to do. There was also debate about providing a false sense of security to refugees and displaced people, accelerating their premature return. Interview with ex-head-office coordinator.Initial explorations in Lofa discovered areas very badly impacted by physical destruction, far more extensive than in the centre or south of the country. MSF’s deployment to north Lofa was also in response to a geopolitical analysis of the risks of a return to armed violence in the sub-region: the proximity to Guinea and Sierra Leone were factors in the decision to deploy in northwest Lofa rather than another region. Lofa was a staging post for LURD, a group that MSF head office felt was the most likely to initiate a renewal in fighting.This is a view I share with the coordination team of the time.

A mission under question: MPH and the Lofa Project

As the peace became increasingly well entrenched, so a number of questions were asked internally about projects that were essentially designed with the idea that fighting would break out. This did not necessarily lead to challenging the validity of these operations, rather to a request that they be modified, a request that came as much from head office as it did from teams on the ground. Few of these questions concerned the Bong project, which centred on providing healthcare access to internally displaced persons: as the camps were slowly emptying of their population thanks to return programmes set up by the HCR, plans were made for progressively winding up their activities.
In Monrovia, the question of the range of care to be provided at the MPH arose very quickly: where to set the limits, and what should be the quality, of the health care on offer? Despite head office reticence about expanding a project that was meant to focus on “emergencies”, the MPH grew relatively quickly; its levels of activity exceeded what the initial plans, and it become more complex from the medical standpoint.
The surgical unit, however, which was designed to treat victims of violence, was not doing so. It was working: it was simply that its activities were not related to violence but rather to the lack of equivalent structures accessible to the Liberian population. The project was also handicapped by a series of problems surrounding management of human resources: a handful of upsetting instances of misappropriation or corruption, conflicts with staff, a series of legal actions (concerning labour law as well as sexual offences involving team members), sometimes extreme tension with the returning Liberian authorities (especially the labour ministry). The question arose as to whether the scope of the MPH should be restricted, allowing it to concentrate on one or two specialities. Paediatrics and mother and infant care, often a focus for humanitarian actors, were already being offered by other MSF sections. For a time there was talk of refocusing on “adult male” patients, the idea being that this group was often overlooked by other aid actors, but the project, focusing as it did on an unusual patient category, never really took off. The innumerable problems of day-to-day management appeared to prevent any in-depth analysis taking place about far-reaching reforms: reading the coordinators’ and mission heads’ monthly reports leaves the impression that the numerous technical challenges that cropped up at various levels in the hospital’s operation effectively paralysed any discussion of the political positioning of a project such as this within the overall scheme of things in Monrovia. In 2005, the project’s results seemed ambiguous: the structure was very busy, but the value of continuing the experiment was questioned because of the amount of energy needed to make it function. It was also hard to justify maintaining a project like this within the relatively peaceful context of Liberia in the post-Taylor years. Did the problem really lie in a post-conflict context where MSF found it hard to establish its place? It might in fact be that what was under question at the time was the idea of what constituted a “legitimate mission” for MSF: the options discussed internally concerning the range of “operational possibilities” offered little chance of a lasting future for the MPH project. This shows that, in 2005, the idea that it was possible to decide to commit long-term support to a population impacted by a war as sustained and violent as in Liberia was not yet common currency. Conversely, in 2010, such an idea was adopted in order to aid the population of Haiti, afflicted by a natural disaster and a singular past. Yet, however singular that country’s past, it would be wrong to deny echoes of the Liberian experience.
The problem in Lofa was of a wholly different nature. Here, the question of MSF’s position within the international aid effort and post-war management of Liberia arose more explicitly. Because of the security situation and the rules imposed by UNMIL, humanitarian organisations that ventured into these areas were at first something of a rarity. The ICRC and MSF-F were the only specialist medical organisations with a presence in Lofa, one of the country’s most populated regions prior to the war, and they agreed on a way of sharing the work between them: MSF-F deployed in west Lofa, ICRC in the east. In reality, this agreement masked a deep-rooted misunderstanding about the role the other was to play in the aftermath of the war. For the ICRC, the Liberian conflict was over, despite the lingering tensions. It wanted to play a part in the reconstruction of a health system utterly destroyed by the fighting. So the ICRC set about rehabilitating and reinstating health services and prepared for the return of Lofa’s population of refugees and displaced people.
MSF France did not share this vision of its role, or the same analysis of the political situation: rather than supporting health centres with the aim of fulfilling a health plan, MSF-F concentrated on two localities with the intention of delivering quality care. It refused to join in the rehabilitation and supervision of health units, despite encouragement from the ICRC (which felt betrayed by this). There are several ways of accounting for MSF-F’s refusal. Playing from time to time a substitution role (there were no public health structures in this part of Lofa at the time) and eager to ensure the quality of the care it provided, MSF-F had neither the financial nor the human resources to get involved in a large number of health structures in this part of Lofa: its way of working (complete substitution) was far costlier than that of the ICRC (support for health centres starting up again).
Beyond even the question of resources, MSF-F had absolutely no desire to play a major role in rehabilitating the health system in Lofa. We have already stated that the organisation considered it highly likely that fighting would break out again. It felt that a policy of reconstruction was premature, as well as sending a dangerous signal to refugees who might think that their safety was now assured. More generally, since the 1990s MSF-F had been unwilling to help promote policies for the rehabilitation of public health systems. After some “unhappy” experiences (at least, that was how they were perceived) in Guinea and Chad during the 1990s, it took the view that managing health districts was not something that fitted its capacities or remit.A far more meticulous historical study is needed concerning the French section’s reluctance to engage in rehabilitating healthcare systems.This was a position that led to a degree of tension within the teams: some members could not understand why certain zones were left without any access to care at a moment when MSF was the only actor able to intervene. Populations in some localities, such as Gondolahun (south of Kolahun) exerted pressure on the Lofa teams. A limited quantity of medicines was distributed via ad hoc mobile clinics, but all in all the coordination teams in Monrovia and Paris remained set in their opposition. MSF-F wished to stay as far as possible outside of any engagement with reconstruction. This position was in stark contrast to operations in Nimba, a region close to Lofa, undertaken by MSF’s Swiss section.

2.1.2. MSF-SWITZERLAND: STRATEGIC POSITIONING IN AN UNSTABLE REGION

MSF-Switzerland (MSF-CH) had not been in Liberia as long as the French section. The Swiss section organised its first activities in the second half of the 1990s. Between 1996 and 1999, it operated in Bong and Nimba, where it provided support to health centres and took part in vaccination campaigns. Curiously, it pulled out of Liberia in late 1999, when northern Liberia was again experiencing armed instability, but not yet Bong and Nimba. The Swiss section handed over its activities to local and international NGOs.Liberia Memory Project.
MSF-CH returned to Liberia in 2002 when the fighting stepped up. After an unproductive exploratory mission in Monrovia, in early 2003 it finally decided to return to a region it knew, southern Nimba, after it saw an influx of Ivorian refugees. So MSF-CH was attracted not so much by the Liberian conflict as by the effects of the Ivorian crisis.The fighting that broke out in Ivory Coast in September 2002 sent a wave of Ivorian refugees into Guinea and eastern Liberia.The Operational Center of Geneva (OCG) was already tackling this issue in Guinée forestière, in the N’Zérékoré area, where it operated in Liberian and Ivorian refugee camps. However, when the MODEL rebel group was created in March 2003 to open a second anti-Taylor front in the Ivory Coast, and fighting spread to the Nimba region, the organisation was forced to suspend its activities in the country, this time for security reasons.MSF-Switzerland did not remain totally inactive. In June 2003, it published Liberian stories, a series of witness accounts on what happened to Liberian populations caught up in the cycle of violence and forced displacements.

Return to post-Taylor Liberia: strategic aspirations or operational conformism?

MSF-CH relaunched its operations in August-September as a fragile peace arrived in the wake of Taylor’s departure. Following two exploratory missions, the first in Monrovia in September and the second in October in Nimba together with MSF-Holland, it set up two projects.
1/ In Monrovia, the project consisted of managing a private secondary care structure in Benson Hospital and supporting two urban health units in Logan and Red Light, two of the capital’s working-class neighbourhoods. The Benson Hospital (80 beds and an OPD) is located in the Paynesville neighbourhood, a disadvantaged area of Greater Monrovia. It provides paediatric and obstetrical care, and aims to specialise increasingly in women’s and children’s health (POA 2004). In 2005, an SGBV (Sexual and Gender Based Violence) unit was opened to provide different forms of support—healthcare, psychological support and legal advice—to women victims of sexual violence. However, the financial difficulties experienced by the Swiss section in 2004 forced it to abandon the costly Benson Hospital project, which was then taken over by MSF Spain (MSF-E). The Spanish section was looking to set up in Liberia and arrived with available funding. After 2004, the Swiss section therefore concentrated on southern Nimba, while MSF-E focused on Monrovia. The two sections used a shared coordination system in the Liberian capital.
2/ In Nimba, the initial project centred on a clinic and small Therapeutic Feeding Centre (TFC) located in the Ivorian refugee camp in Saclepea, along with mobile clinics for pockets of Ivorian refugees and, more especially, the neighbouring Liberian population. MSF-CH’s presence in Nimba in 2004 is explained by the section’s history in Liberia: it returned to this region because it was familiar with it and had operated there twice during the war. Although Nimba did not totally escape the fighting, it was not the region hardest hit by the latest wave of clashes. Similarly to MSF-F, MSF-CH’s interest in Nimba lay in a geopolitical analysis of the Mano River conflicts. Certain members at head office felt that the cycle of armed violence in West Africa was far from over. In view of its proximity to two areas experiencing major tensions, Guinée forestière and the Ivorian West, Nimba seemed to be a useful area for deployment, particularly since the Swiss section was already in place on the other side of the Guinean border (in camps around N’Zéréckoré). In this context, Nimba represented a pre-positioning areaThis pre-positioning policy did, however, cause division at head office. Without rejecting the relevance of the geopolitical analysis, certain MSF-CH members felt that pre-positioning tactics are usually bound to fail (interview with the Liberia desk, Geneva).close to several sensitive regions.In late 2004, the troubles in Ivory Coast and arrival of a fresh wave of 15,000 Ivorian refugees in an area close to Saclepea partially justified the pre-positioning advocates. The aid MSF-CH gave to these refugees was, however, limited due to the presence of the HCR and a health situation that did not appear disastrous (MSFCH, PR 25/11/2004).Nevertheless, this analysis did not seem to take into account that the region was also home to inter-community tensions and the pro-Taylor militia who had withdrawn there. The fact remains that, as for MSF-F, the initial post-conflict period was first analysed with wartime tools. The aim here is not to criticize this analysis after this event, knowing that the war did not actually start up again, but rather to underline the extent to which the conditions initially governing MSF projects in post-Taylor Liberia were linked to practices, or even reflexes, acquired when Taylor was in power.
Nonetheless, the opinions expressed during interviews differ on the subject of the impact of geopolitical analysis on the Swiss section’s choices. Some people felt that it was nothing more than a pretext concocted after the event to justify a deployment resulting from a degree of inertia (“we were already familiar with it”) or a tag-along attitude (“we had to be there too”) rather than an in-depth analysis of the post-2003 situation in Liberia.Interviews with members of the Liberia Desk, Geneva, November 2008.On the other hand, some other documents suggest a more long-term goal and interest in the question of access to healthcare in Nimba. In January 2003, when the war was far from over, the annual action plan revealed a more voluntarist approach and a desire to build an operation in Nimba with more than an emergency scope. “[This] part of the country [...] has already been identified as a potential area of a longer-term intervention. Now it seems to be a priority to identify — apart from the zone of intervention — priority needs of the population living in this remote, but rather stable part of the country.”
In the end, MSF-CH’s interest in Nimba in post-Taylor Liberia was no doubt the result of a combination of several hard-to-separate dynamics: a desire to preposition itself in the Mano River conflicts, an interest in areas soon to be described as “a health desert”The expression is used for Liberia in the January 2005 POA.and possibly also a certain degree of inertia and/or a tag-along attitude that took on more importance over the years.

MSF-CH in Nimba: from tents to brick walls

Whatever the reality, MSF-CH’s activities in Nimba quickly went beyond the context of the Ivorian refugee camp in Saclepea. The teams were convinced that the Liberian displaced residents’ needs were as significant if not more urgent than those of Ivorian refugees.The 2003 POA already revealed a desire to provide aid to Liberians and not just Ivorian refugees.Healthcare was thus offered to everyone, regardless of their official status (resident, IDP or refugee). It initially centred on three areas: external consultations (OPD), hospital beds (IPD, including a small nutritional unit) and a maternity ward. Activities were also extended geographically. In contrast to MSF-F’s activities in Lofa at the same time, the Swiss section tried to spread to the south of Nimba with the goal of covering the area. It organised a mobile clinic that “goes to regions where there are not presently any operational health structures and where security remains tenuous” (activity report, 2003-2004). In 2004, the Swiss took another step in the same direction by providing direct support for fixed health units (two to begin with, then up to eight). MSF-CH rehabilitated or rebuilt structures, subsidised staff and supervised medical activities.Zekepa, Mehnla, Dialah, Yarwein, Zuaplay, Behwallay, Lepula and, of course, Saclepea (Liberia Memory Project).The team put a lot into training staff both at Saclepea and at the fixed units. These activities and its vaccination campaigns led it to work increasingly frequently with the County Health Team (CHT, local representative of the Ministry of Health) that, unlike in areas such as Lofa, had not completely disappeared during the last months of the conflict.
How can this broadening of activities be justified? On the one hand, mobile clinics in this area came up against a great many logistical difficulties and ended up being particularly testing for the teams. On the other hand, monthly activity reports highlighted that the rehabilitation of permanent structures also aimed for medium- and long-term goals: it served firstly to prepare for the population’s return (a little like the ICRC in eastern Lofa) and then to reflect a desire to ensure that the structures support by MSF “reintegrate the public health network.” In 2004, MSF-CH thus began to raise the question of its participation in rebuilding the Liberian healthcare system. However, unlike the activities that developed substantially, discussions on what such participation in the reconstruction process implied did not get very far.
The broadening of activities seemed to be primarily initiated by local teams. The head office naturally followed what was going on in the field and gave their backing to these extensions, but it did not seem to be driving deliberations on the specific targets and the expected implications of such participation in rebuilding a health district. Furthermore, activity reports do not show total commitment to this goal: they oscillated between support for refugee populations and the idea of an investigation of “health deserts.”
The project sometimes gave the impression of freewheeling, especially since the financial stakes were not very high. The autonomy enjoyed by MSF-CH’s Nimba teams contrasts with how the MSF-F teams in Lofa were sometimes reined in by a Paris-based coordination team far more cautious about the consequences of an extension of its activities (in both time and space).
The Liberian mission hardly gave rise to any debate or particular controversy within the Swiss section. The handover of the Benson Hospital to MSF-E resulted from the financial difficulties experienced by the Swiss section and not a desire to pull out of the Liberian project. On the contrary, it was planned to step up specialization at Benson in children’s and women’s health. At head office, a working group on sexual violence was pushing hard for the problem to be included in Liberian programmes. And when the Spanish section took over the Benson project in 2004, Barcelona’s initial reluctance to get involved in this issueMSF-CH, 2005 POA.led
MSF-CH to focus on it in Nimba. The post-conflict situation thus seemed to be favourable to the development of slightly “new” or experimental programmesMSF-CH, 2004 POA: “Projects targeting women (gynaecology/obstetrics, MCH) and children (paediatric care) have been opened or reinforced. These projects have been set up mainly in conflict or post-conflict zones (e.g. Afghanistan, Liberia).”: the end of fighting caused some missions to lose their purpose, and they were then able to switch to more experimental projects. The OCG approached the post-conflict situation in Liberia under this angle.The other possible point was lobbying activity in favour of free healthcare that the 2004 POA prepared for in case the transition government decided to re-introduce the question of cost recovery. This was not the case in 2004.Otherwise, the questions of specific post-conflict challenges and MSF’s role in this type of context were hardly discussed, at least in the archives consulted.There was some discussion in the Swiss section, as revealed by passages in the 2003 POA on public health. These deliberations were, however, expressed in ambiguous terms; “curative and preventive medical action must remain at the very heart of our projects, while public health objectives will have to be subordinated to this central goal” (MSF-CH, 2003 POA 2003). It does not seem that debate on MSF’s role in public health systems affected operations run in Liberia (or vice versa) in the first post-conflict years.This is especially surprising in that, in contrast to MSF-F in Lofa, very early on MSF-CH put its finger on the question of the rehabilitation of the health system by means of its activities in Nimba.

2.1.3. MSF-B: NO CHANGE BETWEEN AT-WAR AND POST-WAR

Like the French section, MSF-B had a long history of presence in Liberia, specifically Monrovia. Since 1999, it had been providing support to the public Redemption Hospital in the capital, particularly the obstetrics and gynaecological departments,This former market became a hospital in the 1980s. The structure was supported by MSF International in the second half of the 1990s, then by MSF-B as of 1999-2000. MSF’s tasks included supervising activities, supplies, training and payment of incentives, often the main form of staff remuneration. The degree of MSF involvement varied according to the departments.as well as five public health centres in working-class neighbourhoods. In parallel with the support provided to public structures, in November 2002 MSF-B also opened a paediatrics department, including a TFC, at Island Hospital, a private structure whose premises it rented to install over 180 beds.We do not know if Island Hospital opened due to lack of space at Redemption (which did have a paediatrics department) or if MSF-B wanted to develop its own structure to avoid the many tensions caused by working in a public structure with staff belonging to the Ministry of Health.Alongside these operational activities, MSF-B also played an advisory and lobbying role for healthcare actors in Liberia. The section alternately defended then criticised the introduction of a healthcare system based on sharing/recovering costs in Liberia.See, for example, “What health, what health care for Monrovia? What role for MSF projects? Analysis of MSF’s role in Monrovia’s health care system”, Dr. Mit Phillips, November 1997.
The final months of the war, in June and August 2003, were marked by a major cutback in activities and withdrawal to the Mamba Point expatriates’ house, converted into a hospital. As soon as it could, the Belgian section opened a Cholera Treatment Unit (CTU) at JFK Hospital.The city’s main hospital, a private institution whose staff were partially remunerated by the MOH.
Once the fighting was over and Taylor had left, the Belgian section relaunched and extended its activities in Monrovian neighbourhoods, maintaining a CTU at JFK Hospital and returning to secondary care structures (Redemption and Island hospitals) and primary structures (the five MOH health centres in working-class neighbourhoods). MSF-B also extended its activities to the displaced persons camps surrounding the city; it opened three healthcare units that it fully managed. The section undertook major rehabilitation work in the structures it supported, particularly at Redemption Hospital.
Outside Monrovia, like other MSF sections, MSF-B initiated various exploratory missions in the counties most affected by the fighting, even (and especially?) when UNMIL had not declared them safety zones. While MSF-F went into Lofa and MSF-CH into Nimba, MSF-B decided to deploy its activities towards the east, in Grand Gedeh county. It provided support for two public structures there: the Zwedru hospital and Ziah Town health centre. Similarly to the French section, it did not really seek to cover an entire health zone.
Overall, it is clear that MSF-B’s operational deployment in the immediate post-conflict period is similar to that of the two other sections examined above: a secondary service in Monrovia, aid for displaced people and deployment in areas affected by the conflict and still almost empty of other humanitarian organizations.
Nevertheless, there are a few notable differences. Firstly, MSF-B played a far more important role in Monrovia: in addition to its hospital-based activities, it managed a primary healthcare network. It was also far more involved in working with the Liberian authorities. Rather than a post-war choice, this represents continuity with the conflict period. Compared to the French and Swiss sections, MSF-B had less of a tendency to plan its activities based on a possible renewal of hostilities in Liberia or the surrounding areas. It is true that since Zwedru,
Brussels had been keeping an eye on the Ivorian west, but its main concerns were already elsewhere. They centred on the part played by the NGO in a Liberian health system that was officially being rebuilt. What role should it play in the post-war context and health system rebuilding process?
Initially, the MSF-B mission seemed to be moving towards a marked decrease in its activities, starting in 2005. Without waiting for the presidential elections, which some feared would trigger a new cycle of violence, the Belgian section officially planned to handover projects for supporting Liberian structures.Annual Report Form, Support to Primary and Secondary Health Care in Monrovia Liberia, Project, (cited by the Liberia Memory Project, 2007).For instance, between March and September 2005, MSF-B withdrew from three of the five urban health centres it supported (after rehabilitation, and usually leaving behind a three-month stock of medicine). In December, the three clinics in the displaced person camps were also closed. In Grand Gedeh, MSF-B handed over its Ziah Town activities to Merlin and planned to close it Zwedru project in June 2006.The opening of a programme in late 2005 to care for tuberculosis patients at Zwedru hospital held up the withdrawal.
And, most importantly, handover of the Redemption Hospital to the Ministry of Health officially began, with MSF medical staff leaving in late November, but came up against numerous difficulties, such as accumulated delays, very tense negotiations with staff, and press accusations saying MSF was abandoning the population. In September 2004, the MSF teams had already experienced a fairly violent strike by the redemption Hospital staff, who were protesting MSF not respecting incentive scales set up by the ministry. This strike possibly influenced MSF-B’s decision to withdraw from the structure and hand over to the ministry. In December 2005, a head office press release officially announced MSF-B’s withdrawal from Redemption Hospital according to a progressive timetable lasting until June 2006. As for Island Hospital, MSF-B also opened discussions on the possibility of the ministry taking over the new structure: in January 2006, it suspended admissions and opened closely-argued negotiations with the health authorities. As the section most with the closest working ties to the ministry, MSF-B gave the impression of also being the section closest to withdrawing. However, it went on not to be the first section to leave Liberia, but the last.

In the immediate post-war period, operations and analyses developed by the different MSF sections tended to converge. This unstable period was still essentially seen through the prism of war and the possible renewal of hostilities (certainly more so for MSF-F and MSF-CH than MSF-B). The period was characterised by the wish to stand out from other NGOs and the UN system, particularly by deploying in remote areas and zones not classified as safe according to UNMIL criteria (here again, MSF-B moved away from this position, at the end of the period).
Between 2003 and 2005, reconstruction was not yet a central question for MSF sections: the continuing uncertainty reigning in Liberia, a weak transition government without the confidence of donors, and the as yet incomplete deployment of the UN and aid organisations meant that many observers continued to describe the situation as “post emergency”, without a strong reconstruction imperative (in comparison with later years). It was therefore easy to avoid the political and mental reconstruction context—until 2005, when the MSF teams had to face the issue: during the tensions opposing MSF-F and the ICRC in Lofa, when MSF-CH extended its activities in Nimba, and during MSF-B’s difficult withdrawal from Redemption Hospital. During the period that followed Ellen Johnson-Sirleaf’s election, the question of the relationship between MSF projects and reconstruction policies became increasingly weighty and the different sections’ operational solutions diverged more markedly.

2.2 GETTING CAUGHT UP IN PEACE (2005-2009)

2005 was a watershed year. It opened with the UNMIL announcing the end of the disarmament process and HCR the official start of operations to resettle refugees and displaced persons. It ended with the election of President Ellen Johnson-Sirleaf, who emerged as the international community’s favourite candidate. It saw the end of the transition government, compromised by the presence of former armed factions, and the return of a real civilian government fuelled by the desire to break with past policies: President Sirleaf announced her intention to build a New Liberia.
In this political context, offering more stability and more reassurance for the international community, measures to coordinate transition and reconstruction policies were stepped up. These measures explicitly aimed to incorporate the activities of humanitarian organisations in medium- and long-term development goals. The International Financial Institutions (IFI) set up planning tools seeking to help Liberia return to the fold. Similarly, mechanisms for putting figures on the state of the country, its people and its economy served to guide reconstruction policies. The process was not new. The task of coordinating and supervising the various actors’ activities in terms of transition policies was already underway in 2003, but it became increasingly pressing and present with the end of disarmament and Johnson-Sirleaf’s election. An increasing number of texts therefore mapped out the needs of the State and the Liberian people: in the healthcare sector, the National Health Plan was drawn up in 2006 to cover the 2007-2011 period. These texts thus delineated the different non-governmental actors’ scope of action. The World Bank returned to Liberia, the UN introduced and tested out the clusters reform in the field, and the Liberian administration was repopulated out and planned to take back control of the country.
As the prospect of renewed fighting diminished and enduring peace took it place, the issues of reconstruction—of the State, but also more broadly of a political, economic and social order—had an increasing impact on humanitarian actors’ thoughts and actions.
As far as the MSF sections were concerned, this served to give more force to the question of the legitimacy of its presence, as well as the relationship between aid organisations. In the immediate post-war period, the different sections were unanimous in insisting on the need to keep a distance from UN coordination bodies, particularity those controlled by UNMIL. This position evolved and took on different shades in the years that followed.
As the country settled into peace, international actors’ priorities began to centre less on maintaining a fragile peace, which seemed to have more or less been achieved, and far more on reconstruction of a “failed State”. The challenge of reconstruction seemed in some ways to be more technical and less political than that of upholding peace. In the eyes of certain actors, including a number of MSF sections, it justified moving cautiously closer to aid bodies. Consequently, the MSF International Office carried out a study on the way in which the various coordination mechanisms set up after the war enabled certain major international actors, like the World Bank and leading donors like USAID, to impose their vision of Reconstruction, aside from the clusters reform. The report felt that if the MSF sections wanted a role in post-conflict Liberia, they had to seek a balance between adhering to the principle of independence and judicious participation in coordination mechanisms.Katharine Derderian, Liberia and the Humanitarian Reform, MSF, International Office, October 2006.

2.2.1 MSF-F ACTIVITIES 2005-2007: ADAPT OR LEAVE

As peace seemed to have settled in for good, the MSF-F mission in Liberia was entering a phase of internal questioning. Although the return of lasting peace removed MSF’s main reason for being in the country, the health situation two years after fighting was over was still worrying, and armed violence had not disappeared, but found an outlet in urban crime. A presentation made by the desk team in September 2005 summed up the teams’ dilemma: “In conclusion, we can say that the war is over but the situation is very difficult for the population, with organised crime and oversight by the UN and private companies.”Extract from the operations report, MSF-F, 27/09/2005.The concept of “artificial peace”, used in the immediate post-war period, fizzled out. Starting in March 2005, the Head of Mission declared in favour of closing the mission. “It seems vital to limit our intervention criteria and maybe learn to leave even earlier, as soon as the acute phase of the crisis is over.” His viewpoint was grounded in a perception of MSF as an “emergency organisation” with no part to play outside acute crisis situations. In the post-conflict context, MSF-F had trouble making a distinction: a growing number of NGOs were intervening in Liberia and deploying in a country officially considered as safe. This fairly substantial presence of “other humanitarian organisations” was felt not only to be a nuisance but also a risk. The Head of Mission felt that the mission could eventually be instrumentalised by the coordination bodies seeking control over reconstruction policies. In 2005 he wrote: “[Leaving earlier] will prevent us from falling victim to the opportunism of international donors, which are well aware that it is wiser to use humanitarian organisations’ know-how to fulfil their moral obligation to help the reconstruction and development process.”

Closure of the Bong and Lofa projects

The Bong and Lofa projects were heading towards closure. The question of closing the Bong project did not need debating: the displaced persons camps were emptying, people were going home. Nevertheless, the end of the project in 2006 triggered major conflicts with some of the national staff who took the dismissals badly. In Lofa, the situation changed significantly in two years: with the end of disarmament and operations to resettle refugees organised by the HCR, a great many NGOs were deploying in the area. The first isolated humanitarian organisations (ICRC and MSF) were followed by organisations centred more on development and reconstruction. In a context where stabilisation was in progress, MSF-F decided to profit from the presence of these organisations to hand over its activities. In Kolahun, IMC agreed to take over MSF projects and all the staff thanks to funding from ECHO. A smooth transition took place in early 2007. In Foya, no one wanted to take over the MSF clinic, built within a private structure unlike at Kolahun. Foya did have another healthcare structure, but the team judged it to be far from adequate in terms of quality and its healthcare was not free. The departure from Foya was painful. Planned for late 2006, it was postponed several times: the teams found it hard to resign themselves to closure and the town’s residents physically opposed MSF’s departure.Interview with a former field manager on the Lofa project.

Closing MPH

The situation was even more delicate in Monrovia. Unlike Lofa, where the level of activities was judged to be moderate and the return of refugee populations was speeding up, the Mamba Point Hospital was a highly active structure from the very start, described in reports as a centre often close to breaking point. The structure was much debated at head office: there were those who pointed the finger at a structure that never functioned in line with initial intentions (caring for victims of the violence) and served as the referral hospital for Central Monrovia’s well-off middle classes; others responded that the MPH was an innovative project at the leading edge of the movement’s efforts to provide hospital care.
The teams in the field were wearing themselves out dealing with a difficult context: recurrent problems with human resources,The field teams felt in particular that, compared to crises more extensively covered by the media, the Liberian mission was not prioritised in the allocation of experienced staff.numerous conflicts with the Liberian authorities, problems in terms of the medical techniques for specific pathologies MSF had to tackle,In 2005, almost a quarter of deaths at the Mamba Point Hospital were linked to chronic illnesses or high blood pressure problems that MSF is not used to treating in conflict situations. In late 2005, the Liberian desk team decided to focus on reducing mortality in the hospital’s medical department (which had the highest mortality rate). The idea was to “set up tools providing a more accurate diagnosis of the situation and be able to identify the curable and treatable diseases with the highest mortality rates” and, where necessary, to introduce suitable treatments (Presentation to operations in December 2005 and Interview with the MSF-F Desk Head, December 2008).the feeling of patients at the end of their ropes who could no longer be helped, etc. Debate over the project’s future really began in 2005, when the teams became aware that Liberia was entering a period of enduring peace,The project documents clearly show this change. In 2004 and 2005, the MPH’s secondary goal was still “to be capable of taking care of the wounded in the event of renewed armed conflict or violence in the city of Monrovia”. In 2005 and 2006, this goal disappears to be replaced by ten or so more medically-oriented objectives (“Set up external consultations for monitoring patients with chronic pathologies”, “Take care of patients with AIDS and introduce ARV”, “Take care of patients with tuberculosis”, “Continue to train hospital teams”, etc.). The goal changed from preparing for a fresh outbreak of war to innovating in the sphere of hospital care in a precarious context.and a Head of Mission arrived and directly raised the question of the legitimacy of MSF’s presence in a post-conflict country: “The discussion took time to get going in 2004, we were lacking in coordination. As of 2005, spurred on by the new Head of Mission, we began to reflect…. How far should we go, how long should we stay in such a context? It is very difficult to answer these questions. Everyone has a different opinion.”Interview with the medical coordinator, MSF-F Liberia.
Consequently, the structure’s future was under debate: should activities be extended, concentrate on specific care categories, or should it be closed? While recognising that the structure provided many services to the city’s residents, some were of the view that it was not part of MSF’s “raison d’être”.The expression that crops up most often in reports and interviews is that the MPH “does not lie within MSF’s mandate.”In May 2006, for instance, the medical coordinator wrote to the desk team: “we should not increase the level of healthcare activities at the hospital, because that would actually mean creating a ‘JFK’ [Monrovia’s main secondary healthcare hospital], which Monrovia no doubt needs, but I don’t think that it is up to MSF.” She urged the desk team to plan on closing the hospital in 2006. Other team members advised recentring MSF-F activities on primary care in disadvantaged neighbourhoods or on surgery. In-the-field discussions on the project’s future went hand in hand with heated debate at head office over the strategic choices open to MSF. The operations management was then pushing for MSF projects to refocus on the “direct victims of violence.” Some people found this view too restrictive or felt that it offered little opportunity for innovative projects. In late 2006, the project was examined twice in the space of three months during Operations meetings. It was decided to maintain the MPH and concentrate on two departments (medical and surgical) and closing two others (obstetrics and paediatrics). The goal was clearly focused on improving MSF’s hospital care expertise. The choice to be present in Monrovia, rather than somewhere else, continued to be justified by the lack of secondary care services (and high mortality rates in the MPH medical department), and the addition of a new goal: to reach the most vulnerable populations in Central Monrovia. However, globally the “new formula” MPH reflected the goal of improving medical techniques (hospital techniques, in this case) rather than a reflection on MSF’s positioning within post-war health development policies. MSF gave itself two years to launch and then assess the project to reconfigure MPH.
However, a year later, a new Operations meeting decided to close down the MPH following some very tense discussions. There are differing versions of the role played by the various people involved. The turnaround can no doubt be explained by the combination of several elements: the idea supported by the Operations management that MSF did not have a role to play in the post-conflict period was a key factor in the decision, but not the only factor. There was also a certain hostility towards major hospital projects, the balance of power between certain head office managers, and considerable lassitude towards the recurrent problems the Liberian mission encountered (particularly the multiplication of legal disputes). The decision was take to close the MPH in mid- 2007. During the December 2006 discussions, the desk team, convinced that they should remain in Liberia, proposed a last project focused on urban violence. The proposal highlighted the fact that MSF already ran a similar project in Haiti. The Operations management was not convinced by the validity of the comparison, but decided to assess the problem in the first half of 2007. This was a last effort to look at the issue of specific Liberian post-war dynamics. Despite the attention paid to this question by the last Heads of Mission, the study did not result in a concrete proposal: they seemed to have had trouble finding an operational and, especially, medical solution to what was essentially a political and social problem. An inter-section MSF study carried out at on healthcare services in Monrovia in late 2004 had also concluded that, from a health standpoint, urban populations were better off than people in rural areas.A conclusion we feel to be too hasty and overly general (see final section).The pro-closure approach won the day. Following a failure to try and hand over to the Indian government, owner of the premises, the MPH closed down in May 2007. And with it ended MSF’s seventeen-year presence in Liberia.
What can we learn from this closure? Firstly, the fact that, contrary to its reputation as “first to arrive, first to leave”, MSF-F took its time to come up with an answer to the question of its presence in post-Taylor Liberia. Not only did MSFF remain in Liberia five years after the end of hostilities, it also hesitated over the options to take and debated extensively on the how to adapt its operations to the new context.
In the end, the idea that prevailed was that MSF did not have a specific role to play in post-Taylor Liberia and, in particular, was not tasked with taking part in health reconstruction policies. This decision reflected both a certain balance of power (at head office and in the field) and the influence of a certain perception of the organisation’s “core business”, i.e. “intervention during a conflict period.” This position contrast with that of the other sections we are looking at.

 

2.2.2. MSF-CH ACTIVITIES: RECONSTRUCTION IN DISGUISE?

A mission that continued to extend

A larger range of healthcare services was being offered at the Saclepea clinic: between 2003 and 2004, the health centre was based on an IPD/OPD, maternity ward and feeding unit. The next two years saw the addition of a tuberculosis programme, AIDS programme, paediatrics service and Sexual and Gender-Based Violence programme (SGBV, rebaptised Women’s Health Unit in March 2006). Starting in the late 1990s, this last issue took on increasing priority within the MSF movement, and more broadly, in the humanitarian aid world. In Geneva, it was driven by several influential figures at the operational centre, including Françoise Duroch.See the May 2004 report “Women”. Liberia was at that point one of six countries where the Swiss section organised SGBV activities, including treatment and different forms of psychological and legal support.
The Swiss section maintained its mobile clinic activity (particularly near the Ivorian border, which was “under surveillance) and stepped up work on supporting health units in southern Nimba: a total of eight health units were built or rehabilitated between 2003 and 2008. In 2005 and 2006, MSF-CH also launched a series of exploratory missions in the south east of the country. Once the financial crisis that had forced it to hand over Benson to MSF-E, MSF-CH was seeking to open a second Liberian project. As in 2003, it was trying to push out the geographical boundaries of its deployment out a little further. In the wake of disarmament, new NGOs set up in Nimba, some of them operating in the health sector. In contrast, the country’s more enclosed areas, like the south east, remained empty of structures and organisations. MSF-CH felt that it was important to go to areas where no other organization was going. “The South East region of Liberia is poorly covered by existing health infrastructure and the humanitarian needs in the region are still quite large and mainly unmet”MSF-CH, 2006 POA.
Exploratory missions were also justified by proximity to the Ivorian border: “The Counties in the South-East corner (Grand Gedeh, River Gee, and Maryland) are also located along the border with Ivory Coast and may face future influxes of refugee populations or other emergency needs if the situation in Ivory Coast remains unstable or explodes with renewed fighting.”Idem.A geopolitical justification of the exploratory missions was provided, as if the lack of health equipment could not justify the extension of the teams’ work alone. In the end, although the exploratory mission reports confirmed the absence or extreme fragility of health structures, the initiative did not result in any concrete decisions. And in 2006, the legitimacy of the Swiss presence in Liberia came under question.

Confused goals

As the Nimba project continued to evolve (see box on the Saclepea project), the reasons underpinning MSF’s presence in the area and Liberia in general started to become confused. In February 2006, the 2006-2007 operational plan defined the situation in Liberia as “post-emergency”, where the main priority was to rebuild a functioning primary care system. The same report underlined the total absence of the Liberian Ministry of Health’s capacity in Lower Nimba: in the light of these conditions, MSF sought to guarantee the region’s population access to primary and secondary care. One of the main projects launched that year was construction of a permanent 50-bed hospital in Saclepea. However, the way the project’s goals were formulated was ambiguous: reconstruction of the Liberian healthcare system was the stated priority, and MSF was embarking on building a permanent hospital, but nothing pointed to a MSF goal of taking part in national reconstruction plans. It is possible that this was not so much an oversight or lack of detail but the fact that the question had not been settled. In the second half of 2006, head office did however take the decision to halt the medical activities in Nimba planned for 2008 (following completion of work at Saclepea and handover of all MSF-managed health structures). This decision was partly linked to a broader discussion at head office on the need to improve MSF’s ability to close down projects once the crisis is over: the MSF-CH 2004-2006 Operational Project deplored the fact that “too often we try to identify uncovered needs in order to stay on leading to difficulties in controlling growth. But crisis situations do come to an end and objectives as initially defined may be reached. In this respect, we should start thinking about exit when starting a given project.”Operational Project, 2004-2006, draft version, MSF-CH, November 2003.
Along the same lines, the 2006-2007 activity report raised the question of closure in Liberia due to a “stabilised context” and the “economic interests” the country was attracting. Nevertheless, in November 2007, the end of mission report by the MSF-CH medical coordinator defines a totally different goal for the mission. He felt that it hinged on “working with other healthcare actors, particularly the MOH, to develop a quality healthcare system for the people of Lower Nimba.” The section’s goals varied with each different report, from preparation for closure, provision of healthcare to a population in need in the post-emergency situation, or implementation of the national health plan drawn up by the authorities. In 2008, the Nimba project was still running. Work on Saclepea Hospital was completed in December 2007, but the mission had found a temporary new raison d’être with a study on ASAQOne of the therapeutic combinations developed by the DnDI (Drugs for Neglected Diseases Initiative) and recommended by the WHO to combat malaria in Africa.in agreement with the Liberian ministry.

MSF-CH and the reconstruction process: discreet participation

Without openly adhering to reconstruction objectives, in effect the Swiss section followed the same route as other medical NGOs (IMC, Médecins du Monde, Africare) involved in rehabilitating the healthcare system. It did however differ from these organisations due to its decision-making autonomy and habitual substitution role.For NGOs like MDM, substitution was something of a frightening prospect, and it tended to be used only as a last resort. Their goal was to systematically work in partnership with the Ministry of Health (Interview with the MDM Liberia desk, Paris, December 2007). MSF-CH felt that, in 2006, the Ministry of Health was still not functioning properly in the field:
“Although there has been some development in the past two years, the overall health infrastructure is still completely inadequate for the general population. The only improvements in the health structure are due to NGOs and their ability to spread further into the countryside to develop more programs. The Ministry of Health does not function at all as an implementing agency. They have not yet begun to implement a real health strategy or have a real presence within the health care system in Liberia. They have no resources and very little staff — almost 100% supported and supplies through NGOs” (MSF-CH, 2006 POA). MSF-CH thus became involved in “reconstruction” while aiming to maintain independent decision-making. For instance, like the other MSF sections, it only took part in the UN health cluster as an observer. Locally, the health authorities were informed and consulted, but MSF-CH kept control over its operations. Due to MSF’s wide-reaching role in the Lower Nimba health district, this sometimes caused major misunderstandings: the County Health Team was only informed at a very late stage of the Saclepea permanent hospital project. On the other hand, the MSF teams only found out about the existence of another public structure in Saclepea supported by Mercy, a Liberian NGO, after work had started. The public health authorities had a problem with the very format of the new MSF unit: firstly, because there was no secondary care unit in Saclepea before the war (the referral hospital was an hour away in Ganta), and secondly because the MSF structure, even reduced to 32 beds, had no equivalent in the Liberian system—no basic health unit or referral hospital—to integrate with, as required. The Liberian public health resources plan therefore had to be modified to incorporate the MSF structure. When the structure was officially inaugurated in December 2007, it kept the name MSF had given it: CHC (Comprehensive Health Center).

The changing face of the MSF-CH Saclepea project
The question of moving from a temporary tent-based structure to a permanent structure had been raised since 2005. During field visit, head office managers were concerned about the “village of tents” built by MSF in Nimba, or made fun of it. For health reasons and to rationalise space, the coordination team therefore decided to change to a permanent structure more suited to hosting medical activities. After spending some time exploring the possibility of transferring hospital activities to the Tapeta hospital, the Swiss finally decided to begin building a permanent structure in Saclepea itself. The project started out ambitiously, planning for 80 to 90 beds, and was then moderated to take into account he possibility of being taken over by the Liberian public health authorities, ending up with 32 beds. When the building work was finished, the Saclepea CHC triggered some debate at head office: some people felt is was a real technological success and concrete contribution to rebuilding the Liberian health system, whereas others made fun of the “referrals monster” that, if it did not empty out after the section left, would encumber the local government’s management capacity.

MSF-CH’s relationship with the reconstruction process was fairly disconcerting. There did not appear to be any real discussion of the challenges and limits of its involvement at head office. Furthermore, MSF-CH’s degree of participation in rebuilding the healthcare system in southern Nimba contrasted with the relative timidity of their political commitment to the issue. In contrast with MSF-B or an organisation like MDM, MSF-CH had not undertaken any major lobbying of government or donors to influence or support reconstruction of the public health system and formulation of new public health policies in post-war Liberia. And yet, in the field, MSF-CH was a key actor in the Nimba region. In addition, the 2005 POA revealed a desire to draw attention to “medical deserts” (“on the medical ‘deserts’ in countries coming out of crisis (Angola, Liberia)”). In the absence of any real discussion of a notion that needed careful handling, the action was essentially limited to a handful of press releases asking for the fate of Liberian people not to be forgotten.
MSF-CH did not join in the campaign led by MSF-B and Save the Children UK to support free healthcare in Liberia. On the other hand, in 2008, it organised a public conference on the treatment of sexual violence. In the wake of the conference, MSF-CH also asked for sexual violence to be recognised as a “national priority” and recommended a “decentralised approach with integrated structures throughout the country” along with the introduction of special training (modelled on the Saclepea Women’s Health Unit).
The history of MSF-CH’s Nimba project thus conjures up a low-key participation in the reconstruction process, discreet, in disguise even. When the mission finally ended in late 2009, the results were far from negative. However, it would not be wrong to ask if the section would have done better by discussing its relationship to post-conflict reconstruction more openly.

Epilogue

As the Liberia mission was ending, the 2008-2011 Operational Plan stressed that “our organization is suffering from a ‘this is not MSF’ syndrome which tends to restrict initiative, progress and to favour the implementation of standard rules without an understanding of their raison d’être and their natural need to evolve with time. Anything can become an MSF practice from the moment it is relevant to the people we assist”. This appeal to deliberation possibly came too late to trigger discussions o n MSF-CH’s role in the post-Taylor Liberian reconstruction process.

2.2.3. MSF-B: RECONSTRUCTION VIA LOBBYING

As regards MSF-B, we can recall that 2005 was meant to usher in a massive reduction in activities, or even a forthcoming closure, for the Liberian mission. However, this opinion was reversed during the year, re-energising MSF-B’s mission.

Renewed energy starting in 2006

While projects were being successfully handed over, the Liberian mission received a number of visits from head office, particularly the AAU/Analysis and Advocacy Unit. This unit was exploring the operational impact of free healthcare: having supported cost recovery in the 1990s, in 2003 MSF-B committed to a contrasting policy of lobbying for free healthcare.It is difficult to accurately date this reversal, but it was partially linked to a wide-reaching survey on access to healthcare that MSF-B carried out in Burundi in late 2003 (cf. Mit Philips, Inma Vazquez and Armand Sprecher, “Good donorship in practice: the case of Burundi”, Humanitarian Exchange Magazine, no. 29, march 2005).Post-conflict situations seemed favourable to promoting messages of this kind. People were still fragile and impoverished, and the free care standpoint could draw on the idea of a necessary transitional period during which payment of care by patients should be suspended, or not reintroduced. MSF-B had supported this policy in other post-conflict context, like Burundi and Sierra Leone. There were those who pushed for this action to be extended to Liberia. In August 2005, a visit from the AAU led to the production report recommending strong action against the temptation to reintroduce cost recovery in Liberia.Suspended since September 2003.In September 2005, an AAU manager circulated a text within MSF criticising “the isolationist attitude” of certain MSF missions, and recommending that links be established with other actors to influence public health policies at certain decisive moments.“Action unique, parole unique, pensée unique: à un pas du contrôle de la pensée et de la Complaisance. MSF et les gardiens de la pensée unique de l’humanitaire », Mit Philips, September 2005. The next month, the AAU produced a similar text for the La Mancha discussions. This text cites post-crisis situations like Burundi and Liberia where MSF still had a role to play thanks to its political influence and knowledge of health issues.“MSF and access to healthcare: in-the-field experience in lobbying for a change of policy”, Mit Philips, October 2005.It was particularly important to protect local populations in post-conflict situations from too sudden a return to development processes based on cost recovery.This position was also supported by other participants, such as Egbert Sondorp (former MSF-H board member and lecturer at the London School of Hygiene and Tropical Medicine) who advanced the idea of a transitional post-crisis space wherein MSF still had a major role to play. He explicitly referred to Liberia in a text written for La Mancha (Sondorp, “Creating ‘transitional space’”, My sweet La Mancha, MSF, December 2005, p.288-290).
These ideas on MSF’s reforming role in the post-war and reconstruction contexts were passed on by operational department heads and re-energised MSF-B’s Liberian mission. The lobbying action meant that MSF had to know how to identify the different actors and their policies, to be able to establish links with them, and to manage to influence their decisions while continuing to head operations in the countries concerned. MSF-B also had to proof itself capable of producing information that could back up its recommendations regarding health policies. While making sure that it maintained its independence of action, MSF-B become involved, to a greater degree than the other sections, in a series of discussions with other aid actors, and particularly with the Ministry of Health and its donors. This is why a liaison officer in charge of Liberian and Sierra Leonean questions was sent to the field in 2006.
Other actors, however, stressed that this lobbying action was not the only reason behind MSF-B’s continuing presence in Liberia beyond 2006. Firstly, from an operational standpoint, 2006 saw a growing investment in Island Hospital. Having attempted to hand it over to the Ministry of Health, the Belgian section finally decided to take entire responsibility for the hospital, which specialised in paediatrics. The number of beds continued to rise: 50 in 2002, 65 in 2003, 122 in 2006 and 187 in 2008. Secondly, MSF-B’s presence can be explained by the teams’ uneasiness when faced with the difficulties caused by closing down projects and the question of handing over activities. Some opinions had it that maintaining the mission was linked less to the desire to influence the general direction of post-war health policies and more to the difficulties of finding satisfactory exit strategies.Interview with the MSF-B Head of Mission, Monrovia, February 2009.We can well ask whether development of the Island Hospital project was not directly linked with the tensions caused by the difficult way that the Redemption project ended (tensions with the authorities and the staff as well as the teams’ discomfort with withdrawal that sometimes made them feel they were abandoning the population). An internal MSF-B document specified the line to take in response to questions from the press and Liberian authorities:
“Did you make the wrong decision by leaving Redemption? No. It made it possible to intensify the work at Island Hospital and to help many that we were not able to help while we were working at Redemption. I do regret that Redemption is not functioning well. The responsibility of the problems at Redemption is a collective responsibility and is shared by international donors, MSF and the government of Liberia”.“Redemption handover. Main messages”, undated, unsigned. MSF-B Liberian Mission archives.
Following a series of handovers in 2005 and 2006, MSF-B operations found a new raison d’être by focusing on an entirely private hospital structure and a group identified as particularly vulnerable in the post-war period: children. This new impetus has several causes: the difficulty in closing existing projects and the choice of concentrating on a paediatrics hospital combined with the action of lobbying for free healthcare to revitalize the Liberian mission.

From free healthcare to closure (2007-2010)

The Belgian section made a special lobbying effort during the international donors conferences that met in Washington in February 2007 to discuss Liberia. To coincide with the conference, the Belgian section published a report entitled “No cheap solution for health care in Liberia: From emergency relief to development” (9 February 2007). MSF-B alerted donors to the difficult transition between emergency operations and development phase. As humanitarian actors that substituted the public authorities withdrew, MSF-B felt that a major investment effort was needed in the health sector. The report also supported maintaining free healthcare, citing the example of Redemption Hospital where the partial reintroduction of cost recovery led to a significant drop in attendance after MSF’s departure.
It is difficult to assess the impact of MSF-B’s lobbying policies in this area. Free healthcare has been maintained in Liberia until the present day. The Belgian section’s efforts certainly helped, although other actors also supported the same position (ECHO). In addition, a UNICEF report underlined that the Liberian government did not have much in the way of other options that maintaining free healthcare in view of the population’s poverty.
The Belgian section found it more difficult to call donors’ attention to the need to support paediatrics hospitals in Monrovia. The Belgian and Spanish sections together covered 80% of this form of care in 2008. This meant that donors were basically participating in reconstruction of the primary care system within the country and the introduction of a Basic Package of Health Services (BPHS), a policy the ministry adopted in 2008.
After the relative success of 2007’s lobbying activities, the Belgian section again raised the question of closing down its projects in Liberia. In 2008, a new plan to close activities was put in place, with a schedule reaching until late 2009. The teams’ biggest concern was Island Hospital. The structure had undergone rapid growth that the teams felt was necessary due to the lack of equivalent structure in the country (Island grew from 50 to 187 beds between 2002 and 2008). In 2009, the ECHO representative believed that its size was a serious obstacle to being taken over by the Ministry of Health. MSF-B finally handed the structure over to the Ministry of Health in June 2010, without, as far as we know, having found any international donors to support the structure. It is still too soon to know what will happen to the hospital in the years to come.

2.3 CONCLUSION

Comparing the operations led by the three MSF sections in Liberia reveals both strong areas of convergence and deep-reaching differences over the analysis of post-conflict humanitarian aid.
In the immediate post-war period, the three sections set up fairly similar operations, tackling the Liberian situation with interpretative mechanisms inherited from wartime. As peace became established, these mechanisms for analysis lost their relevance, questions arose on the legitimacy of MSF’s presence and operational policies began to vary from one section to the next. MSF-F spent some time hesitating between several options for its urban hospital, but after a heated debate finally decided it did not have a role to play in a country that was in the hands of the “developers”. It was thus the first to leave. In late 2005, MSF-B was preparing to leave when a broader current of thought, mainly initiated by head office, reinvigorated the mission: it set itself the goal of influencing reconstruction policies and better managed its own exit strategies. The results of this choice are not yet known, and are only outlined here. MSF-CH also remained longer than MSF-F and became involved in a process to rehabilitate a health district. MSF-CH was no doubt the section that took the greatest role in the process to rebuild the health system—the process as perceived by the aid system. However, the Swiss section did not acknowledge this reconstructive role and, in contrast with MSF-B, hardly discussed its specific goals in this area. In the end, despite their differences, the three sections closed down their projects and left the country in a fairly short space of time (2007-2010).MSF-B did however maintain a reduced presence in 2010 in Liberia, and MSF-F sent an exploratory mission there, although it did not lead to a decision to open a mission.
Aside from the actual policies, it is interesting to note the extent to which post-Taylor Liberia triggered debate, in the field and at head office, on MSF’s intervention contexts and the possible roles the organisation might or might not choose to play. There were those who felt that post-Taylor Liberia represented a risk of drifting off course and possibly getting bogged down in development approaches that did not correspond to MSF’s “core business”. Other rejected this notion of “core business” and called on MSF to be less isolationist, more innovative and more responsible in the difficult situations of post-conflict transition. This study’s purpose is not to sanction any particular opinion. However, it is interesting to note that most deliberations at that time took the Reconstruction issue seriously. Both those who believed that MSF had no place in the post-war period and their opponents all ended up accepting the terms of debate as laid out by the key aid players’ dominant view (see part 1). To some extent, the terms of the debate triggered by the post-conflict situation were not questioned, but taken as read: post-conflict humanitarian issues did in fact merge with reconstruction issues; the choice was to participate or not participate. In the following section, we will try to highlight the political choices underpinning the Reconstruction message and stress the value in questioning humanitarian post-conflict issues with analysis perspectives other than transition, reconstruction and development.

3. ALTERNATIVE ANALYSES: A DIFFERENT POST-CONFLICT CONTEXT, DIFFERENT HUMANITARIAN ISSUES?

The dominant views, based on rebuilding a failed State, the URD continuum and the New Liberia, influenced all actors in the aid world. Even for those who chose to remain outside the systems that produced them, these views continued to model the analysis perspectives used to understand the dynamics of post-conflict Liberia.

3.1. REVISITING THE FACTS: A PEOPLE ON ITS KNEES IN A DEVASTATED POST-WAR COUNTRY?

To say that a country is devastated by war and that its people come out of the conflict on their knees is nothing out of the ordinary. Post-Taylor Liberia was no exception, especially since the violent fighting with its succession of men in wigs and child soldiers made an impression on the international media. In response to the tales of destruction, “reconstruction” naturally emerged as the dominant theme, particularly in the healthcare domain. However, the relationship between the war and the health situation in Liberia is more complicated than it first appears. Reports that began to appear in 2003 to assess the health situation in Liberia testified to an extremely worrying situation. These figures justified the idea of a necessary and massive investment in rebuilding the health system. However, in the absence of quantitative data, difficult to produce in the immediate post-war period, most reports were based on figures dating from the 1990s, or even the period before the war. In 2007, the DHS (Demographic and Health Survey), carried out in line with international standards, was meant to provide decision-makers with health indicators and simultaneously report on the worrying condition of the people.LISGIS, MOHSW & Macro International Inc., Liberia Demographic and Health Survey 2007 (June 2008).Although the survey revealed a far from positive situation, it also reported some surprising figures. For instance, the improving health and life expectancy among some segments of the population during the war. According to the DHS, child mortality, one of the most widely used indicators after the war, had been dropping steadily since the 1980s, including during the war. Other surveys also revealed somewhat surprising situations: for example, many observers expected a high HIV-positive incidence among the Liberian population after the war and the accompanying sexual violence.As far as we know, this link between an increase in the HIV epidemic and rape has not been proven. However, it is often confirmed by aid actors in the conflict situations.However, the incidence seemed relatively low (1.5%),Liberia Demographic and Health Survey 2007. equivalent to Guinea and Sierra Leone and lower than their Ivorian neighbours (4.7% in 2005)The Ministry of Health’s “Survey on AIDS Indicators” and Ghana (2.2% in 2003). Another example is the survey produced by the ACF organisation in February 2008 on the nutritional conditions in the urban environment, which revealed more worrying figures than in inland rural areas even though they had been declared underserved and were thus a priority for food and nutritional aid.
We can of course choose to ignore some of these results, as the fruit of surveys using dubious methodology. This applies to the 2007 DHS: many observers agree in saying that it was based on faulty or totally out of date demographic data. But we could also consider that these fragmentary and sometimes questionable data encourage us to revise hasty judgements on the links between war and health.
Prior to the war, the main healthcare provided in Liberia came from the private sector, often missionaries or linked to concessionary companies, a sector inaccessible to most people. With the war, hundreds of thousands of people, particularly very young people, took refuge in a succession of camps in Liberia or abroad, where they benefited from relatively unprecedented access to curative and preventive medicine (particularly vaccinations). It is not unreasonable to think that, paradoxically, the health conditions of certain age categories improved because of their forced exodus to the camps.
We are not saying that the war was a positive phenomenon for Liberians’ health. But we need to qualify the idea of total destruction of the health economy and uniformly severe downward trend in health indicators. The situation was far more complex: for certain populations, fleeing their homes paradoxically resulted in improved access to healthcare. For some other groups, the war brought damage to healthcare structures and their ensuing inaccessibility. It is thus possible that the mother-child health indicators, closely monitored by international NGOs, improved while the condition of other groups deteriorated. The MSF-F Desk adopted the same analysis at Mamba Point Hospital when they refocused treatment on uncared for groups: “Adult men were the ones whose health has been neglected.”Interview with the head of the MSF-F Liberia Desk, December 2008.We do not wish to deny the impact the conflict had on the Liberian population’s health. What we do want is to put an end to the perception of post-Taylor Liberia as a tabula rasa where everything needed rebuilding. We would also like to qualify our analyses and understand health situations that were more nuanced than the perspective rooted in the shadow State and barbaric wars would allow.

3.2. RECONSTRUCTING THE POLITICAL DIMENSION OF THE RECONSTRUCTION PROCESS: AID WHERE PEOPLE ARE/AID TO WHERE WE’D LIKE THEM TO BE

The notion of “reconstruction” of a failing State was purportedly grounded in the international community’s generosity and solidarity with the Liberian people. Above all, it gave the impression of being based on facts and common sense: in the wake of a war, the next step was clearly reconstruction. And yet, the words and actions relating to rebuilding the New Liberia also encompassed political stakes linked primarily to rebuilding law and order, a concern shared by the new regime and key international players (see first section). One of the major questions arising in the aid world just after the war was how to manage displaced populations, representing over a third of the Liberian population. To kick-start Liberia, its State and its economy and ensure law and order, the various national and international authorities wanted to return all displaced people to their homes. The refugee displaced persons camps were seen to be areas lacking in law and order and a potential source of trouble. Monrovia’s poor and overpopulated neighbourhoods were seen as a breeding ground for crime and opposition (several riots broke out in Monrovia, all blamed on “ex-fighters”). Aid actors were roped in to contain this “threat” in the guise of participating in “reconstruction”. The UN agencies, particularly the HCR and its implementing partners, were in charge of taking Liberians back to their “native region”, sometimes with the support of UNMIL soldiers or the Liberian police to calm down the streets of Monrovia and “encourage” IDPs to leave.See Michel Agier’s analysis in Vacarmes, no. 40, 2007.
The imperatives of political management of the people had a direct impact on humanitarian organisations and the choices they were encouraged to make in distributing aid. The question was, where should aid in post-Taylor Liberia be directed? Should it be distributed where the people were, and thus focus on Monrovia, which was home to 40 or 50% percent of inhabitants? Or should it be allocated to the place the population were meant to return toThe place it was supposed they wanted to return to.and get back to work (rural areas, particularly plantations and mining areas in the north)? International actors and the new Liberian government made a pretty clear decision: aid would go to useful areas (rural zones) and not to support the “useless” and “dangerous” people still massed in the ghettos of Grand Monrovia. The argument was never expressed in such direct terms, but was suggested far more subtly: the war in Liberia was described as the fruit of an historical imbalance between the “natives”, the people living inland, and the Americo-Liberian elite, primarily urban. So as not to repeat the mistakes of the past, it was therefore necessary to invest in underserved areas (to use the terminology in vogue among texts produce by the World Bank and United Nations in Liberia), i.e. rural areas. Aid was thus directed at rural areas in the name of the poor and vulnerable. Another stated rationale was the necessary levelling out of an historical imbalance linked to the very origins of the Liberian republic. The argument was not lacking in logic— apart from the fact that many of the underserved were then gathered in the urban areas that were no longer reserved for the Congo elites alone.We use the term to mean the descendants of the Afro-American colonisers who made up the political and social elite of the Liberian republic from the outset. See Stephen Ellis, The Mask of Anarchy, 1999.
These decisions in the geographical distribution of aid were fairly clear to see in the National Health Plan and the priority it gave to primary care structure in rural areas with the least services. Monrovia and the health needs of its million and a half inhabitants were pushed into the background. However, it is not MSF’s place to judge these policies; in their concern for law and order and, doubtlessly, as a matter of conviction, the government and its international support felt that the return of people to rural areas was the best guarantee of an enduring return to stability; all efforts were concentrated on that purpose, and thus the aid machine too. However, it is important to understand this policy and the consequences for vulnerable populations. They had a difficult choice: return to the rural areas they came from to receive aid, or remain in the camps and squats and manage by themselves. In deconstructing the reconstruction messages and policies, it is possible to come up with other possibilities for humanitarian intervention.

3.3. OTHER POSSIBILITIES: FROM IDPS TO THE DISPOSSESSED IN THE NEW LIBERIA

When we shift from the question of humanitarian organisations’ role in reconstruction to the effects of the political choices tied to reconstruction, other figures emerge and open the door to other operational projects.
In the months following Johnson-Sirleaf’s election, the Liberian authorities endeavoured to reconquer the spaces occupied by squatters, such as plantations, mines and, especially, Monrovia’s urban areas. Useable urban space was relatively rare and land prices soared with the arrival of a huge wave of international actors. In just a few months, thousands of inhabitants were encouraged or forced to leave their homes. Rehousing solutions were wholly inadequate. Some of these former squatters no doubt returned to the rural areas they had come from, for want of a better solution, but many stayed in the capital and crammed into the poorest and most insalubrious outlying neighbourhoods of Grand Monrovia. These are the “dispossessed”, a traditional figure in West African urban history, but totally absent from the traditional categories used for humanitarian intervention. The MSF-F and MSF-B teams took some interest in them by investigating the ghettos, but without identifying a convincing operational intervention format. The MSF International Office survey conducted in Liberia in 2006 also asked the teams to think about “collateral victims” of Reconstruction policies.“Several factors strongly suggest that the clusters in Liberia will define common strategies to be imposed on all participants. These include the already high level of UN integration, the proliferation of coordination structures adopting common posi tions (e.g. MSG), historical experiences of politicization such as the IDP return and the potential for fusion between the clusters and the LRDC’s four-pillars process. One key humanitarian actor expressed concern that such common positioning risks ‘collateral damage’ of populations not covered by assistance, such as non-returning IDPs. The question is if and how an independent actor like MSF should meet the needs of populations neglected in the UN or World-Bank led processes.” (Katharine Derderian, Liberia and the Humanitarian Reform, MSF, International Office, October 2006).
Like the IDPs, the dispossessed were running away, although not from the same thing: fighting in one case, the law and the police in the other. They differed in every other respect. In Liberia, IDPs were a central figure, greatly in evidence, familiar to the humanitarian systems. The dispossessed, on the other hand, were newcomers living on the margins of society and hard to pin down in two ways: they did not exist as a legitimate intervention category, and unlike IDPs, they tended to be dispersed rather than concentrated by their flight. However, if we retrace some of their journeys, we might find that many of these “dispossessed” were themselves former IDPs who arrived in Monrovia at different periods of the war. Did the displacement caused by war create more health needs than post-war evictions? The answer is unclear: the rate of malnutrition in urban areas reported by ACF in post-Taylor Monrovia and the recurrent cholera episodes that MSF treated indicate that the area has major health needs, which could possibly be linked to this new generation of displaced people, those still on the run after the war. Getting a better understanding of this issue would entail tackling health problems in Monrovia from a different angle: not from the overly diffuse perspective of urban development, which discourages or paralyses some MSF sections, but from the viewpoint of aiding a very specific population, a displaced population who are in danger, exhausted from successively fleeing the armed militia then the new power’s forces of order. A post-conflict intervention outside the province of reconstruction is one possible solution among others; such a solution arises once we consider the post-conflict situation otherwise than solely in the light of the Reconstruction paradigm.