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Fixing a Broken Humanitarian System That Is Failing Refugees’ Health

In an excerpt from The Lancet, refugee health expert Paul Spiegel argues that the humanitarian system is broken and urges wholesale reform, outlining four ways that humanitarians need to change to be equipped for future public health action in crises.

Written by Paul Spiegel Published on Read time Approx. 5 minutes
A man stands in a doorstep in front a wall reading ‘I need a doctor’ in a migrant shelter in Belgrade, Serbia, on January 18, 2017. Nebojsa Markovic/Citizenside

An unprecedented number of humanitarian emergencies of large magnitude and duration are taking place, from Syria to South Sudan and Yemen.

The humanitarian system was not designed to address the types of complex conflicts that are happening at present. It is not simply overstretched – it is no longer fit for purpose.

The recent crises, exemplified by the unprecedented level of forced displacement in a generation, the Syrian crisis and its spillover into Europe and the Ebola epidemic in West Africa, have highlighted failures of a system that have been evident for some time.

Based on my experience as a senior official at the U.N. refugee agency (UNHCR) in the past decade and as an academic in humanitarian emergencies research, I suggest four sets of actions that would help to make the humanitarian system fit for future public health responses.

Centrality of Protection: Put Words into Action

Centrality of protection means that the core of policies and interventions for persons affected by conflict or natural disasters must address the rights of all individuals, with an emphasis on age, sex and diversity.

In medical terms, centrality of protection is similar to a modern interpretation of the Hippocratic Oath, with which doctors pledge that the rights and needs of the patient are at the core of everything they do.

Protection actors like myself have tried to articulate that protection principles are not solely legalistic and human rights imperatives; rather, they are life-saving and life-improving interventions that are an integral part of every response. Action is needed to help people, not simply new laws and policies that can be difficult to enforce.

Public health interventions should not need to prove how they support protection goals, since they do so by their very nature. However, they must be protection- sensitive; examples include ensuring that latrines can be locked from the inside and surrounding areas are well lit, and that healthcare providers are trained to respond to gender-based violence and can manage data confidentiality.

The concept of community-based protection is essential to ensure that the voices of communities are heard and affect change. This requires operational field persons who are trained in protection, not lawyers who specialize in human rights principles and law.

Protection actors must not put themselves above other sectors, but should become part of all sectors, such as health, nutrition and shelter. They must move away from pontificating that all interventions must be protection-sensitive, towards assisting humanitarian actors to ensure that such interventions are easy and practical.

Integrate Refugees into National Healthcare Systems

The humanitarian-development gap has been recognized as a major challenge for decades. The development of countries will be negatively affected if humanitarian emergencies are not addressed in a complementary manner with development assistance.

How can humanitarian action transition into long-term development, and how can development actors implement resilient programs that prepare communities for future emergencies?

Creating alternatives to camps, if done well, should allow refugees and internally displaced people (IDPs) to live with dignity, independence and normality as members of a community, and should also benefit the host community and the local economy.

From contingency planning to response, existing district, regional and national healthcare strategies should take into account where the affected displaced populations should be or are located. Even when governments insist on establishing camps, they should be seen as settlements and planned according to the development plan of that district or region.

The establishment of parallel healthcare systems should be avoided except when existing systems cannot be quickly capacitated to respond or when humanitarian principles such as humanity, neutrality, impartiality and independence cannot be maintained.

Existing national healthcare posts, clinics and hospitals should be capacitated with material, financial, technical and human resource support as needed. Compensation must be provided for the temporary disruption of national cost-recovery systems as free healthcare services need to be provided to affected populations during the acute phase of the emergency.

All persons in a particular area affected by a humanitarian emergency should receive protection and assistance, irrespective of whether they are nationals, economic migrants or forcibly displaced. These groups may face differences in legal rights, international law, choices and coping mechanisms, and these differences need to be factored into the design of programs. The challenge is to bolster a non-discriminatory approach without affecting standards, speed of response, humanitarian principles and space, and accountability for results.

A Major Revision of Leadership and Coordination

Leadership and coordination of humanitarian emergencies have become too complex and process-oriented in the past decade.

From my personal experience and from many evaluations and reports, the current humanitarian leadership and coordination structures such as the Cluster Approach are too cumbersome, bureaucratic, inadequate in terms of effect and accountability, dominated by developed countries, and insufficiently adapted to constantly changing environments. Coordination has become a means to an end.

The complexity and diversity of humanitarian emergencies require a different leadership style and alternative coordination models. A good response to emergencies relies on a strong command and control structure with a designated leader who can make difficult decisions on the basis of needs, not politics or relationships.

Coordination by consensus and provision of space to all agencies who wish to respond do not work in large-scale emergency responses. A more customized approach delivered in varying combinations with the ability to flexibly scale up and down is needed.

We need a wholesale reform of humanitarian leadership and coordination and not the piecemeal iterative approach that has occurred with the outcomes of the World Humanitarian Summit.

Be More Efficient, Effective and Sustainable

Humanitarian responses have expanded in the past decade from a Band-Aid approach addressing immediate needs to one that seeks long-term solutions from preparedness to resilience.

Humanitarian organizations are now expected to deal with social safety nets, livelihoods and people’s well-being in protracted settings for decades. Realistic expectations on what humanitarian action can and should achieve must be agreed upon.

Much more can be done to improve efficiencies and effectiveness and to ensure sustainability of humanitarian interventions. Data and research will be indispensable.

Furthermore, multiyear committed funding is needed for humanitarian organizations to work within the government healthcare development plans and with development actors on integration into national healthcare systems. The inefficiencies of providing humanitarian funding on an annual basis with no commitments to continued funding for long-term projects are large and wasteful.

The UNHCR and its partners are already using health insurance and other existing government social safety net programs in some protracted refugee settings such as Ghana and Iran. Further exploration of different health financing models such as pay-for-success financing and humanitarian bonds as well as health insurance needs to occur for humanitarian emergencies.

The current humanitarian system was created for a different time. Major changes to the system will require operationalizing the concept of centrality of protection, finally addressing the humanitarian-development nexus, remaking humanitarian leadership and coordination and making interventions more efficient, effective and sustainable.

To succeed, certain governments, the U.N. and international organizations will need the political will to relinquish authority, influence and funding.

This is an edited excerpt from The Humanitarian System Is Not Just Broke, but Broken: Recommendations for Future Humanitarian Action published in The Lancet as part of a special series on health in humanitarian crises; the full series is available online here.

The views expressed in this article belong to the author and do not necessarily reflect the editorial policy of Refugees Deeply.

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