The Humanitarian System is Not Just Broke, but Broken: recommendations for future humanitarian action Paul B. Spiegel MD, MPH Professor, International Health, Johns Hopkins Bloomberg School of Public Health Director, Center for Humanitarian Health, Johns Hopkins University

of Forced Displacement Magnitude and Cost of Forced Displacement

Figures for Forced Displacement (end of 2016)

Refugees (end of 2016)

Internally Displaced Persons (IDPs – end of 2016)

Funding for Humanitarian Assistance (end of 2016)

Funding for Humanitarian Assistance (end of 2016)

Humanitarian Norms and Current Trends

The Humanitarian ‘Norm’ was… (and still is) Low income countries in Sub- Saharan Africa Corinne Baker/MSF, 2013 South Sudanese refugees in Kenya Mandel Ngan, 2013 Za’atri refugee camp, Jordan

The Humanitarian ‘Norm’ was… (and still is) Low income countries in Sub- Saharan Africa Persons in refugee camps Corinne Baker/MSF, 2013 South Sudanese refugees in Kenya Mandel Ngan, 2013 Za’atri refugee camp, Jordan

The Humanitarian ‘Norm’ was… (and still is) Low income countries in Sub- Saharan Africa Persons in refugee camps Weak governments and few functioning national NGOs Corinne Baker/MSF, 2013 South Sudanese refugees in Kenya Mandel Ngan, 2013 Za’atri refugee camp, Jordan

The Humanitarian ‘Norm’ was… (and still is) Low income countries in Sub- Saharan Africa Persons in refugee camps Weak governments and few functioning national NGOs Communicable diseases Corinne Baker/MSF, 2013 South Sudanese refugees in Kenya Mandel Ngan, 2013 Za’atri refugee camp, Jordan

Current Trends Prolonged crises >90% of countries with humanitarian crises had humanit. appeals for >3 years

Current Trends UN and Int’l NGOs receive funds Prolonged crises >90% of countries with humanitarian crises had humanit. appeals for >3 years UN and Int’l NGOs receive funds UN agencies and largest INGOs received 81% of humanit. assistance (2009-2013) Local and national NGOs directly received just 0.2% of total humanit. assistance (2014)

Current Trends Increasing, new and complex mix of actors Prolonged crises >90% of countries with humanitarian crises had humanit. appeals for >3 years UN and Int’l NGOs receive funds UN agencies and largest INGOs received 81% of humanit. assistance (2009-2013) Local and national NGOs directly received just 0.2% of total humanit. assistance (2014) Increasing, new and complex mix of actors Increasing number with varying competence National gov’ts and local NGOs taking lead Middle East gov’ts, Islamic agencies, and priv. sector

Syria

Future Humanitarian Action Recommendations for Future Humanitarian Action

Recommendations for Future Humanitarian Action Operationalise concept of ‘centrality of protection’ Integrate affected persons into national health systems by addressing humanitarian-development nexus Remake not simply revise leadership and coordination Make interventions more efficient, effective and sustainable Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017; (Series: Health in Humanitarian Crises): 45-52.

Operationalise concept of ‘centrality of protection’ Recommendations: Interpret centrality of protection in inclusive manner Interpret centrality of protection in inclusive manner where health interventions are considered basic lifesaving protection interventions, while ensuring such health services are protection-sensitive Always translate resolutions and laws into practical responses with concrete actions that can be monitored to sanction state and non-state actors who violate them Do not restrict population movements nor undertake mandatory testing in humanitarian emergencies except under exceptional circumstances

Operationalise concept of ‘centrality of protection’ Recommendations: Interpret centrality of protection in inclusive manner Translate resolutions and laws into concrete actions including sanctions Interpret centrality of protection in inclusive manner where health interventions are considered basic lifesaving protection interventions, while ensuring such health services are protection-sensitive Always translate resolutions and laws into practical responses with concrete actions that can be monitored to sanction state and non-state actors who violate them Do not restrict population movements nor undertake mandatory testing in humanitarian emergencies except under exceptional circumstances

Recommendations: Operationalise concept of ‘centrality of protection’ Interpret centrality of protection in inclusive manner Translate resolutions and laws into concrete actions including sanctions Do not restrict pop. movements nor undertake mandatory testing in humanit. emergencies except under exceptional circumstances Interpret centrality of protection in inclusive manner where health interventions are considered basic lifesaving protection interventions, while ensuring such health services are protection-sensitive Always translate resolutions and laws into practical responses with concrete actions that can be monitored to sanction state and non-state actors who violate them Do not restrict population movements nor undertake mandatory testing in humanitarian emergencies except under exceptional circumstances

Integrate affected persons into national health systems by addressing the humanitarian- development nexus Recommendations: Take into account existing development health strategies in situations where existing systems cannot be quickly capacitated to respond, when humanitarian principles cannot be upheld, or security reasons are paramount important differences in terms of legal rights, international law, choices and options, and coping mechanisms according to status of affected persons

Integrate affected persons into national health systems by addressing the humanitarian- development nexus Recommendations: Take into account existing development health strategies Integrate affected pop. into national health systems; avoid parallel health services in situations where existing systems cannot be quickly capacitated to respond, when humanitarian principles cannot be upheld, or security reasons are paramount important differences in terms of legal rights, international law, choices and options, and coping mechanisms according to status of affected persons

Integrate affected persons into national health systems by addressing the humanitarian- development nexus Recommendations: Take into account existing development health strategies Integrate affected pop. into national health systems; avoid parallel health services Compensate for temporary disruption of national cost-recovery systems in situations where existing systems cannot be quickly capacitated to respond, when humanitarian principles cannot be upheld, or security reasons are paramount important differences in terms of legal rights, international law, choices and options, and coping mechanisms according to status of affected persons

Integrate affected persons into national health systems by addressing the humanitarian- development nexus Recommendations: Take into account existing development health strategies Integrate affected pop. into national health systems; avoid parallel health services Compensate for temporary disruption of national cost-recovery systems Equitable access to quality health services should be available to all persons in specific area regardless of status in situations where existing systems cannot be quickly capacitated to respond, when humanitarian principles cannot be upheld, or security reasons are paramount important differences in terms of legal rights, international law, choices and options, and coping mechanisms according to status of affected persons

Remake not simply revise leadership and coordination Recommendations: Undertake wholesale reform of humanitarian leadership and coordination More customised approach Fewer UN and int’l operational agencies Prioritisation of key interventions by leader with sufficient authority Undertake wholesale reform of humanitarian leadership and coordination More customised approach delivered in varying combinations with ability to flexibly scale up & down is needed rather than ‘set’ package Fewer UN and international agencies that are operational should be chosen to respond in certain large scale emergencies Prioritisation of key interventions must occur by a leader who has sufficient authority Monitor closely UN and INGOs who must relinquish some influence and authority Monitor closely WHO’s humanitarian reform process to ensure fundamental changes are made Rebecca Blum, Haiti, 2010

Remake not simply revise leadership and coordination Recommendations: Undertake wholesale reform of humanitarian leadership and coordination More customised approach Fewer UN and international operational agencies Prioritisation of key interventions by a leader with sufficient authority Monitor closely UN and INGOs who must relinquish influence and authority Monitor closely WHO’s humanitarian reform process to ensure fundamental changes are made Undertake wholesale reform of humanitarian leadership and coordination More customised approach delivered in varying combinations with ability to flexibly scale up & down is needed rather than ‘set’ package Fewer UN and international agencies that are operational should be chosen to respond in certain large scale emergencies Prioritisation of key interventions must occur by a leader who has sufficient authority Monitor closely UN and INGOs who must relinquish some influence and authority Monitor closely WHO’s humanitarian reform process to ensure fundamental changes are made Rebecca Blum, Haiti, 2010

Make interventions more efficient, effective and sustainable Recommendations: Provide upfront investment by donors in health and WASH infrastructure Recommendations: Provide upfront investment by donors in health and WASH infrastructure at the beginning of an emergency recognising that refugees and IDPs will likely be in protracted settings; this will save money in the long run (donors, private sector). Initiate multi-year funding for health, nutrition and WASH-related activities to allow for sustainable interventions that will improve integration into and national health services in the coming years (donors, private sector). Actively and systematically scale up cash-based transfers, particularly multi-purpose cash transfers, in humanitarian emergencies following context-specific assessments (donors, private sector). Undertake research on conditional and unconditional CBTs as well as remittances for health, WASH and nutrition interventions in humanitarian emergencies to build up the evidence base and provide future guidance. Explore different health financing models for humanitarian emergencies such as pay for success financing and other social impact bonds as well as health insurance (all partners). Provide guidance according to context and data as to which sectors should be prioritised according to need and which interventions within sectors should prioritised according to efficacy and cost-effectiveness (all partners).

Make interventions more efficient, effective and sustainable Recommendations: Provide upfront investment by donors in health and WASH infrastructure Initiate multi-year funding Recommendations: Provide upfront investment by donors in health and WASH infrastructure at the beginning of an emergency recognising that refugees and IDPs will likely be in protracted settings; this will save money in the long run (donors, private sector). Initiate multi-year funding for health, nutrition and WASH-related activities to allow for sustainable interventions that will improve integration into and national health services in the coming years (donors, private sector). Actively and systematically scale up cash-based transfers, particularly multi-purpose cash transfers, in humanitarian emergencies following context-specific assessments (donors, private sector). Undertake research on conditional and unconditional CBTs as well as remittances for health, WASH and nutrition interventions in humanitarian emergencies to build up the evidence base and provide future guidance. Explore different health financing models for humanitarian emergencies such as pay for success financing and other social impact bonds as well as health insurance (all partners). Provide guidance according to context and data as to which sectors should be prioritised according to need and which interventions within sectors should prioritised according to efficacy and cost-effectiveness (all partners).

Make interventions more efficient, effective and sustainable Recommendations: Provide upfront investment by donors in health and WASH infrastructure Initiate multi-year funding Actively and systematically scale up cash-based transfers Recommendations: Provide upfront investment by donors in health and WASH infrastructure at the beginning of an emergency recognising that refugees and IDPs will likely be in protracted settings; this will save money in the long run (donors, private sector). Initiate multi-year funding for health, nutrition and WASH-related activities to allow for sustainable interventions that will improve integration into and national health services in the coming years (donors, private sector). Actively and systematically scale up cash-based transfers, particularly multi-purpose cash transfers, in humanitarian emergencies following context-specific assessments (donors, private sector). Undertake research on conditional and unconditional CBTs as well as remittances for health, WASH and nutrition interventions in humanitarian emergencies to build up the evidence base and provide future guidance. Explore different health financing models for humanitarian emergencies such as pay for success financing and other social impact bonds as well as health insurance (all partners). Provide guidance according to context and data as to which sectors should be prioritised according to need and which interventions within sectors should prioritised according to efficacy and cost-effectiveness (all partners).

Make interventions more efficient, effective and sustainable Recommendations: Provide upfront investment by donors in health and WASH infrastructure Initiate multi-year funding Actively and systematically scale up cash-based transfers Explore different health financing models Provide guidance on prioritisation Recommendations: Provide upfront investment by donors in health and WASH infrastructure at the beginning of an emergency recognising that refugees and IDPs will likely be in protracted settings; this will save money in the long run (donors, private sector). Initiate multi-year funding for health, nutrition and WASH-related activities to allow for sustainable interventions that will improve integration into and national health services in the coming years (donors, private sector). Actively and systematically scale up cash-based transfers, particularly multi-purpose cash transfers, in humanitarian emergencies following context-specific assessments (donors, private sector). Undertake research on conditional and unconditional CBTs as well as remittances for health, WASH and nutrition interventions in humanitarian emergencies to build up the evidence base and provide future guidance. Explore different health financing models for humanitarian emergencies such as pay for success financing and other social impact bonds as well as health insurance (all partners). Provide guidance according to context and data as to which sectors should be prioritised according to need and which interventions within sectors should prioritised according to efficacy and cost-effectiveness (all partners).

Summary Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017.

Summary Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017.

Summary Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017.

Summary Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017.

Forgotten Emergencies

Forgotten Emergencies South Sudan

Forgotten Emergencies South Sudan Central African Republic

Forgotten Emergencies South Sudan Rohingyha conflict in Myanmar Central African Republic Khin Maung Win, AP, 2012

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