“We tell them to sit, listen to information, and take their medicine”: perceptions, practices, and potential for community engagement within MSF
Authors: Schittecatte G , Pellechia U , Meudec M , Vanlerberghe V 
Published: July 2024

INTRODUCTION
Community engagement (CE) rose to prominence with the Alma Ata Declaration in 1978, and remains a concept lauded by global health actors, including MSF. CE is often described as being linked with accountability, ownership, and sustainability of health programmes. It is also linked with social determinants of health through its empowering principles. Despite the recognition of its importance, challenges remain in incorporating
CE into programmes.

METHODS
We used a qualitative, case-based approach to explore how community engagement is defined, perceived, and evaluated in MSF contexts. Our aim was to identify challenges and opportunities in truly integrating communities into humanitarian health interventions. Three projects were purposively selected, in Democratic Republic of the Congo, Lebanon, and Venezuela, aiming to represent a variety of health programmes, as well as societal diversity. Document review and 55 semi-structured interviews were conducted. Participants represented different institutional levels and positions, as well as national and international staff. Interviews were transcribed and coded iteratively, as were the operational and technical documents, institutional policies, and reports included in the document reviews. The themes that emerged in the iterative coding were
then analysed.

ETHICS
This study was approved by the MSF Ethics Review Board, and by the Institutional Review Board at the Institute of Tropical Medicine, Antwerp, Belgium.

RESULTS
We found disparity between MSF institutional policy, operational documents, and incorporation of CE at programme level. While there is policy acceptance of CE as essential, interviews show that MSF barely engages with communities in a participatory process. There is little prioritisation of CE, and lack of guidance on the processes needed to involve communities in decision making. Our results also show that despite shared claims of the importance of CE, definitions, objectives, and evaluation all vary significantly. Tensions emerge between seeing communities as active participants or as passive beneficiaries. Additional tensions appeared around whether CE was perceived as an approach for promotion of quality of care and accountability of operations, or purely as an activity to reach the organisation’s goals. Finally, while field projects may establish links with communities, MSF remains the sole decision-maker on the overall medical-humanitarian strategy. Interviewees questioned the capability of MSF to work within this community engagement approach, due to inherent power asymmetries and the predominant use of western-centred biomedical approaches. Inequalities and misconceptions between international and national staff created an additional barrier to bridging with
local communities.

CONCLUSION
If MSF is interested in improving its approach to CE, there should be a concerted effort to change the way communities are viewed with respect to the organisation‘s interventions. While a single model of CE is not possible, MSF needs to set up training on CE approaches and develop frameworks and clear objectives for CE, through dedicated resources at headquarters and field levels.

CONFLICTS OF INTEREST
None declared.