Revisiting Sphere: new standards of service delivery for new trends in protracted displacement

The proportion of people living in protracted displacement, as well as the duration of this displacement, is increasing. International humanitarian standards for services provided in protracted displacement are based on the Sphere Standards, which were formulated using evidence and experience from acute phase emergencies. However, the majority of protracted emergencies are in the post‐emergency phase. This paper discusses trends in displacement, outlines reasons why using the Sphere Standards as minimum standards of service provision in protracted displacement does not adequately meet the needs of these populations, and analyses areas where greater standards of service provision are necessary. An expansion of the evidence base regarding determinants of morbidity and mortality in protracted emergencies is needed. This, followed by a joint approach to designing new, effective standards focused on proactive policies, will allow the humanitarian community more appropriately to serve and enable the millions of people currently living in protracted displacement.     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.     

Providing health services during a civil war: the experience of a garrison town in South Sudan

The impact of conflict, particularly conflict arising during civil wars, on the provision of healthcare is a subject that has not been widely considered in conflict‐related research. Combatants often target health services to weaken or to defeat the enemy, while attempts to maintain or improve health systems also can comprise part of counter‐insurgency ‘hearts‐and‐minds’ strategies. This paper describes the dynamics associated with the provision of health services in Malakal, an important garrison town in South Sudan, during the second Sudanese civil war (1983–2005). Drawing on the concepts of opportunity hoarding and exploitation, it explores the social and political dynamics of service provision in and around the town during the war. These concepts provide a useful lens with which to understand better how health services are affected by conflict, while the empirical case study presented in the paper illustrates dynamics that may be repeated in other contexts. The concepts and case study set out in this paper should prove useful to healthcare providers working in conflict zones, including humanitarian aid agencies and their employees, increasing their understanding of the social and political dynamics that they are likely to face during future conflict‐related complex emergencies.     

Rebuilding and strengthening health systems and providing basic health services in fragile states

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations' ability to deliver good-quality services in the long run.     

The future of humanitarian action: mapping the implications of Iraq and other recent crises

In late 2003 the Feinstein International Famine Center, in partnership with institutions in London, Geneva and Washington, organised a series of consultations on the future of humanitarian action post-Iraq. This article is based on those discussions. A number of recurring concerns are elaborated, ranging from the perception of humanitarianism as a Northern-driven and Northern-controlled enterprise, through the politicisation of security and the devaluation of the protective power of emblems, to the very nature of how the crisis in Iraq is perceived. The article explores the implications of such issues for humanitarian workers and their institutions. It concludes by framing an agenda for action by the humanitarian sector.     

The mental health of expatriate and Kosovar Albanian humanitarian aid workers

The mental health consequences of exposure to traumatic events and the risk factors for psychological morbidity among expatriate and Kosovar Albanian humanitarian aid workers have not been well studied. In June 2000, we used standardised screening tools to survey 285 (69.5%) of 410 expatriate aid workers and 325 (75.8%) of 429 Kosovar Albanian aid workers from 22 humanitarian organizations that were implementing health programmes in Kosovo. The mean number of trauma events experienced by expatriates was 2.8 (standard deviation: 2.7) and by Kosovar staff 3.2 (standard deviation: 2.8). Although only 1.1% of expatriate and 6.2% of Kosovar aid workers reported symptoms consistent with the diagnosis for post-traumatic stress disorder, 17.2% and 16.9%, respectively, reported symptoms satisfying the definition of depression. Regression analysis demonstrated that the number of trauma events experienced was significantly associated with depression for the two sets of workers. Organisational support services may be an important mediating factor and should be targeted at both groups.     

The impact of humanitarian context conditions and individual characteristics on aid worker retention

High employee turnover rates constitute a major challenge to effective aid provision. This study examines how features of humanitarian work and aid workers’ individual characteristics affect retention within one humanitarian organisation, Médecins Sans Frontières (MSF) Holland. The study extends existing research by providing new theoretical explanations of employment opportunities and constraints and by engaging in the first large‐scale quantitative analysis of aid worker retention. Using a database of field staff (N=1,955), a logistic regression is performed of the likelihood of reenlistment after a first mission. The findings demonstrate that only 40 per cent of employees reenlist for a second mission with MSF Holland, and that workplace location and security situation, age, and gender have no significant effect. Individuals are less likely to reenlist if they returned early from the first mission for a personal reason, are in a relationship, are medical doctors, or if they come from highly developed countries. The paper reflects on the findings in the light of policy.     

Humanitarian governance and the consequences of the state‐fragility discourse in the Democratic Republic of Congo's health sector

This paper examines how the discourse on state fragility affects the preferences of key actors in humanitarian governance for different types of health‐sector interventions in the Democratic Republic of Congo. It argues that, instead of focusing on the actual meaning of state fragility, attention should be paid to interactive processes around the discourse among stakeholders in the health sector. The lack of consensus on state fragility influences humanitarian governance, especially the perceptions of and interactions between the host government, donors, and international non‐governmental organisations. The latter have legitimised the persistence of vertical, emergency‐based interventions by emphasising state fragility, whereas state officials have preferred to assert political statehood and a higher degree of control. Nevertheless, they agree that donors’ financial contributions ensure the survival of the public health sector. Looking ahead, a policy coalition based on harmonised views about addressing fragility is necessary for effective engagement and the sustainability of interventions, but this is unlikely to happen any time soon.     

Rethinking access: how humanitarian technology governance blurs control and care

Surprisingly little attention is paid to the role of digital technology and related forms of data production, storage, processing, and sharing in humanitarian governance. This paper uses Michael Barnett's ( 2013 ) conceptualisation of humanitarian governance when arguing for a better accounting of technology in literature on humanitarian governance. Specifically, it proposes a two‐fold alertness to governance of (a) the uses of new technology and (b) that which is produced by digital technologies. This elucidates important issues, including that of access to digitalised data collected from humanitarian subjects, with implications for their (in)security. The paper concludes by suggesting that access is no longer ‘only’ about challenges of gaining access to vulnerable populations, but also about challenges of preventing access to vulnerable digital bodies and their use for aggressive purposes. In short, access and protection acquire a new dimension and analyses of humanitarian governance must be more attentive to the role of digital technology.     

The humanitarian common logistic operating picture: a solution to the inter‐agency coordination challenge

Although significant progress has been made in developing the practice of humanitarian logistics, further improvements in efficiency and effectiveness have the potential to save lives and reduce suffering. This paper explores how the military/emergency services’ concept of a common operating picture (COP) can be adapted to the humanitarian logistics context, and analyses a practical and proven approach to addressing the key challenge of inter‐agency coordination and decision‐making. Successful adaptation could provide the mechanism through which predicted and actual demands, together with the location and status of material in transit, are captured, evaluated, and presented in real time as the basis for enhanced decision‐making between actors in the humanitarian supply network. Through the introduction of a humanitarian logistics COP and its linkages to national disaster management systems, local communities and countries affected by disasters and emergencies will be better placed to oversee and manage their response activities.     

Anatomy of an ambush: security risks facing international humanitarian assistance

The 2003 war with Iraq has generated security concerns that present unique challenges to the practice of providing international humanitarian assistance during war and conflict. Objective research studies on security management are lacking. However, case studies have proven to be an important education and training tool to advance situational awareness of security risks. These challenges are illustrated by an analysis of the events surrounding the first ambush of, and assassination attempt on, a senior US aid official in Baghdad. Before deployment to conflict areas, especially those characterised by insurgent activity, humanitarian providers must realistically assess the threats to life and to the mission. They must obtain pre-deployment situational awareness education, security training and optimal protective equipment and vehicles.     

A tale of two cities: restoring water services in Kabul and Monrovia

Kabul and Monrovia, the respective capitals of Afghanistan and Liberia, have recently emerged from long-lasting armed conflicts. In both cities, a large number of organisations took part in emergency water supply provision and later in the rehabilitation of water systems. Based on field research, this paper establishes a parallel between the operations carried out in the two settings, highlighting similarities and analysing the two most common strategies. The first strategy involves international financial institutions, which fund large-scale projects focusing on infrastructural rehabilitation and on the institutional development of the water utility, sometimes envisaging private-sector participation. The second strategy involves humanitarian agencies, which run community-based projects, in most cases independently of the water utilities, and targeting low-income areas. Neither of these approaches manages to combine sustainability and universal service. The paper assesses their respective strengths and weaknesses and suggests ways of improving the quality of assistance provided.     

Putting affected people at the centre of humanitarian action: an argument for the principle of humanitarian subsidiarity

The humanitarian system has grown organically over the course of a generation to become a complex system bound by a common primary mandate. Its guiding principles provide it with a unique identity and separate humanitarian actors from other aid-related stakeholders. However, all of the evidence suggests that humanitarian actors will extend their reach and engage in new and unprecedented ways with an expanded mandate in years to come. Now, more than ever, they are challenged to retain the moral high ground and to put disaster-affected people at the centre of humanitarian action. Consequently, this paper proposes that the humanitarian system introduce a new principle: humanitarian subsidiarity. It moves the conception of subsidiarity beyond meanings ascribed by the Catholic Church and the European Union and links it instead to the attributes of agency, accountability, and trust to find accommodation with the core humanitarian principles of humanity, impartiality, neutrality, and independence.     

Humanitarian (in)security: risk management in complex settings

Attacks against humanitarian aid workers have received increasing attention in the media, particularly high-profile incidents such as those against the hospitals of Médecins Sans Frontières in Afghanistan, Syria, and Yemen. Concurrently, scholarly research has given rise to a number of articles, white papers, and books on humanitarian insecurity. Most of this work centres on external threats, neglecting the internal mechanisms that humanitarian organisations use to mitigate security situations. This paper builds on the existing literature by focusing on the decision-making processes of humanitarian organisations, drawing on data collected from 16 security managers or advisers. The findings reveal that several factors contribute to contextual uncertainty and complexity, including recipient perceptions, local government actions, the behaviour of other non-governmental organisations (NGOs) in the area, logistical issues, risk variance within a single location, and organisational mandate. Furthermore, the results indicate that NGOs utilise a combination of decision-making processes to determine how to manage security in high-risk environments.     

Humanitarian Crises: What Determines the Level of Emergency Assistance? Media Coverage,Donor Interests and the Aid Business

This paper proposes a basic hypothesis that the volume of emergency assistance any humanitarian crisis attracts is determined by three main factors working either in conjunction or individually. First, it depends on the intensity of media coverage. Second, it depends on the degree of political interest, particularly related to security, that donor governments have in a particular region. Third, the volume of emergency aid depends on strength of humanitarian NGOs and international organisations present in a specific country experiencing a humanitarian emergency. The empirical analysis of a number of emergency situations is carried out based on material that has never been published before. The paper concludes that only occasionally do the media play a decisive role in influencing donors. Rather, the security interests of Western donors are important together with the presence and strength of humanitarian stakeholders, such as NGOs and international organisations lobbying donor governments.     

The Death of Humanitarianism?: An Anatomy of the Attack

Over recent years, the humanitarian community has been under increasing scrutiny and attracted harsh criticism. This mounting critique of humanitarianism has shifted from being concerned primarily with the poor functioning of the humanitarian system to one targeted on basic humanitarian values. This paper is concerned to understand the factors driving the attack on humanitarian values. It identifies four apparently disparate groups who are interested in attacking these values: the anti-imperialists, the realpolitikers, the developmentalists and the neo-peaceniks. It concludes that unless humanitarian actors are aware of these diverse threats to their values and operations, they risk being co-opted or marginalised.     

Humanitarians' ethics: the role of face-to-face experiences in humanitarian aid workers' motivation

This paper analyses the significance of specific ethical experiences for humanitarian aid workers' motivation. Following Emmanuel Levinas's understanding of ethics as arising from intersubjective face-to-face encounters, the study illuminates the experiential origins of the humanitarian commitment by analysing James Orbinski's memoir entitled An Imperfect Offering: Dispatches from the Medical Frontline. Orbinski, a former International Council President at Médecins Sans Frontières, was directly involved in humanitarian responses to several major crises during the 1990s, including those in Somalia, Afghanistan, Rwanda, and what was then Zaire. This paper explores three formative experiences from Orbinski's childhood and teenage years to analyse the personal ethics of humanitarian aid workers and to illuminate the intersection of the personal and professional level of humanitarian aid work. Illustrating that Orbinski's humanitarian commitment is a surrendering to the other's call, the paper argues for stronger inclusion of aid workers' lives and experiences to achieve a comprehensive understanding of humanitarian work.     

The impact of the Gulf crisis on Qatar's humanitarian sector

The 2017 Gulf crisis is one of the most challenging episodes faced by Qatar since its independence in 1971, with major economic, social, and political impacts on the Arab Gulf nation. Its economic prognosis has been brought into doubt, the map of regional alliances has been redrawn, and any prospects of deeper regional integration have been dashed. This paper analyses the little-documented impact of the crisis on Qatar's humanitarian sector, which has unfolded as the small, gas-rich emirate has striven to become a major humanitarian donor. It concludes that while there have been disruptions to humanitarian operations and regional coordination, the Gulf crisis has triggered and in some cases accelerated already intended reforms across the Qatari humanitarian sector. In the long term, the reorganisation and adaptation implemented to weather the storm of the crisis may help Qatar to emerge from the crisis with a more sustainable and resilient humanitarian sector.     

Establishing moral bearings: ethics and expatriate health care professionals in humanitarian work

Expatriate health care professionals frequently participate in international responses to natural disasters and humanitarian emergencies. This field of practice presents important clinical, logistical and ethical challenges for clinicians. This paper considers the ethics of health care practice in humanitarian contexts. It examines features that contribute to forming the moral landscape of humanitarian work, and discusses normative guidelines and approaches that are relevant for this work. These tools and frameworks provide important ethics resources for humanitarian settings. Finally, it elaborates a set of questions that can aid health care professionals as they analyse ethical issues that they experience in the field. The proposed process can assist clinicians as they seek to establish their moral bearings in situations of ethical complexity and uncertainty. Identifying and developing ethics resources and vocabulary for clinical practice in humanitarian work will help health care professionals provide ethically sound care to patients and communities.     

Standardising and mapping open-source information for crisis regions: the case of post-conflict Iraq

Painting an accurate picture of the situation on the ground in countries in crisis is vital for the efficiency of humanitarian aid and reconstruction agencies. This study describes a method for standardising and mapping the plethora of open-source information. The test site for the study is post-conflict Iraq. Important information on aid distribution, reconstruction and security in Iraq can be derived from the reports of humanitarian aid agencies and the media, before being formatted, inserted into a database and mapped. The product is a visual, cartographic structure of otherwise random information, showing which organisations are working in the country, which thematic and geographic areas are being prioritized in the field, and which areas most frequently experience security events. This type of mapping not only highlights the overall working environment within different parts of the country, but it may also serve as a decision-making tool for donors and humanitarian aid agencies planning to deploy personnel.