Mental and social health in disasters: the Sphere standards and post‐tsunami psychosocial interventions in Asia

The primary objective of this paper is to examine and inform the mental health and psychosocial support standards of the 2011 edition of the Sphere Project's Humanitarian Charter and Minimum Standards in Humanitarian Response. This is done through a qualitative analysis of internal evaluation documents, reflecting four long‐term humanitarian psychosocial programmes in different countries in post‐tsunami Asia. The analysis yielded three overall conclusions. First, the Sphere standards on mental health and psychosocial support generally are highly relevant to long‐term psychosocial interventions after disasters such as the Indian Ocean tsunami of 26 December 2004, and their application in such settings may improve the quality of the response. Second, some of the standards in the current Sphere handbook may lack sufficient guidance to ensure the quality of humanitarian response required. Third, the long‐term intervention approach poses specific challenges to programming, a problem that could be addressed by including additional guidance in the publication.     

The Sphere Project: The Implications of Making Humanitarian Principles and Codes Work

In 1996, in recognition of concerns about humanitarian response efforts, non- governmental organisations (NGOs) launched the Sphere Project, the first collaborative initiative to produce globally applicable minimum standards for humanitarian response. The aims of the Sphere Project are to improve the effectiveness of humanitarian efforts and to enhance the accountability of the humanitarian system, primarily to those people who have a right to protection and assistance in disasters, as well as to agency members and donors.
This paper discusses the purpose of the Sphere Project, the unique process that brought it about and the major concerns that have been raised about its practical application. Finally, the paper considers the implications of this for improving the impact of humanitarian response and for future initiatives given the process that Sphere has begun. It argues that improved accountability does not start and stop with NGOs. They are just one element of a wider humanitarian response effort and more needs to be done to improve the system as a whole.     

Violence and complex humanitarian emergencies: implications for livelihoods models

This paper explores the nature of the violence that characterises complex humanitarian emergencies and the related implications for modelling livelihoods systems. While noting the importance of livelihoods approaches in complex humanitarian emergencies, it deliberates the limitations of sustainable livelihoods frameworks when applied in environments marked by protracted instability. Adaptations to the model are discussed, with a particular focus on the relationships among violence, assets and liabilities within livelihoods systems. Political economy of violence theories intimate that the assets on which livelihoods systems are constructed in peaceful times may instead become life-and livelihood-threatening liabilities in periods of conflict. Adaptations to livelihood systems in violent settings require that analysts consider violence from policy, institutional and process perspectives. It is suggested that vulnerability should be re-conceptualised as endogenous to livelihoods systems in violent settings. Building on the work of others, a livelihoods model adapted for complex humanitarian emergencies is presented.     

Linking rights and standards: the process of developing "rights-based" minimum standards on food security, nutrition and food aid

This article examines the recent revision of the Sphere Minimum Standards in disaster response relating to food security, nutrition and food aid. It describes how the revision attempted to incorporate the principles of the Humanitarian Charter, as well as relevant human rights principles and values into the Sphere Minimum Standards. The initial aim of the revision was to ensure that the Sphere Minimum Standards better reflected the principles embodied in the Humanitarian Charter. This was later broadened to ensure that key legal standards and principles from human rights and humanitarian law were considered and also incorporated, in part to fill the "protection gap" within the existing standards. In relation to the food security, nutrition and food aid standards, it was agreed by participants in the process that the human right to adequate food and freedom from hunger should be incorporated. In relation to more general principles underlying the Humanitarian Charter, itself drawn largely from human rights and humanitarian law, it was agreed that there was a need to strengthen "protection" elements within the standards and a need to incorporate the basic principles of the right to life with dignity, non-discrimination, impartiality and participation, as well as to explore the relevance of the concept of the progressive realisation of the right to food. The questions raised in linking rights to operational standards required thought, on the one hand, about whether the technical standards reflected a deep understanding of the values expressed within the legal instruments, and whether the existing standards were adequate in relation to those legal rights. On the other hand, it also required reflection on how operational standards like Sphere could give concrete content to human rights, such as the right to food and the right to be free from hunger. However, there remain challenges in examining what a rights-based approach will mean in terms of the role of humanitarian agencies as duty-bearers of rights, given that the primary responsibility rests with state governments. It will also require reflection on the modes and mechanisms of accountability that are brought to bear in ensuring the implementation of the Minimum Standards.     

Locating responsibility: the Sphere Humanitarian Charter and its rationale

Criticised by some as a technical initiative that neglects core principles, Sphere was seen by its originators precisely as an articulation of principle. The Humanitarian Charter was the main vehicle through which this was expressed, but its relationship to the Minimum Standards has remained a matter of uncertainty. Specifically, it was unclear in the original (1999) edition of Sphere how the concept of rights informed the Minimum Standards. The revised (2004) edition goes some way to clarifying this in the way the standards are framed, yet the link between the standards and the charter remains unclear. The concern with the quality and accountability of humanitarian assistance, which motivated the attempt to establish system-wide standards through the Sphere Project, was accompanied by a desire to establish such actions in a wider framework of legal and political responsibility. In part, this reflects the conditional nature of the undertaking that agencies make when they adopt Sphere. This aspect of the charter has been neglected, but it is fundamental to an understanding of the standards and their application. This paper considers the rationale of the Sphere Humanitarian Charter and the conceptual model that underpins it. It discusses the relationship between the charter and the Minimum Standards, and the sense in which the latter are properly called "rights-based" (explored further in a related paper herein by Young and Taylor). The author was closely involved in the conception and drafting of the charter, and this paper attempts to convey some of the thinking that lay behind it.     

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health‐related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.     

Privatisation and outsourcing in wartime: the humanitarian challenges

The tendency today to privatise many activities hitherto considered the exclusive preserve of the state has given rise to sharp debate. The specific nature of humanitarian emergencies elucidates in particularly stark contrast some of the main challenges connected to the privatisation and outsourcing of essential public services, such as the provision of drinking water and health care. Privatising the realms of defence and security, which are at the very core of state prerogative, raises several legal and humanitarian concerns. This article focuses on the roles and responsibilities of the various parties involved in armed conflicts, especially those of private companies engaged in security, intelligence and interrogation work, and in the provision of water supply and health services. It highlights the need for humanitarian and development actors to grasp better the potential risks and opportunities related to privatisation and outsourcing with a view to supplying effective protection and assistance to communities affected by war.     

Changing tracks as situations change: humanitarian and health response along the Liberia–Côte d'Ivoire border

In recent years, protracted crises and fragile post‐conflict settings have challenged the co‐existence, and even the linear continuum, of relief and development aid. Forced migration has tested humanitarian and development paradigms where sudden‐onset emergencies, violence and displacement arise alongside ongoing development work. Drawing on Médecins Sans Frontières interventions in the region from December 2010 to May 2011, this paper examines aid and healthcare responses to displacement in Côte d'Ivoire and Liberia; it focuses on challenges to the maintenance of preparedness for such foreseeable emergencies and to adaptation in response to changing situations of displacement and insecurity. This ‘backsliding’ from development to emergency remains a substantial challenge to aid; yet, in exactly such cases, it also presents the opportunity to ensure access to medical care that is much more urgently needed in times of crisis, including the suspension of user fees for medical care.     

The Sphere Project: the implications of making humanitarian principles and codes work

In 1996, in recognition of concerns about humanitarian response efforts, non-governmental organisations (NGOs) launched the Sphere Project, the first collaborative initiative to produce globally applicable minimum standards for humanitarian response. The aims of the Sphere Project are to improve the effectiveness of humanitarian efforts and to enhance the accountability of the humanitarian system, primarily to those people who have a right to protection and assistance in disasters, as well as to agency members and donors. This paper discusses the purpose of the Sphere Project, the unique process that brought it about and the major concerns that have been raised about its practical application. Finally, the paper considers the implications of this for improving the impact of humanitarian response and for future initiatives given the process that Sphere has begun. It argues that improved accountability does not start and stop with NGOs. They are just one element of a wider humanitarian response effort and more needs to be done to improve the system as a whole.     

Cross-sectional survey methods to assess retrospectively mortality in humanitarian emergencies

Since the rates and causes of mortality are critical indicators of the overall health of a population, it is important to evaluate mortality even where no complete vital statistics reporting exists. Such settings include humanitarian emergencies. Experience in cross-sectional survey methods to assess retrospectively crude, age-specific, and maternal mortality in stable settings has been gained over the past 40 years, and methods appropriate to humanitarian emergencies have been developed. In humanitarian emergencies, crude and age-specific mortality can be gauged using methods based on the enumeration of individuals resident in randomly selected households—frequently referred to as a household census. Under-five mortality can also be assessed through a modified prior birth history method in which a representative sample of reproductive-aged women are questioned about dates of child births and deaths. Maternal mortality can be appraised via the initial identification of maternal deaths in the study population and a subsequent investigation to determine the cause of each death.     

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.     

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.     

Preventing corruption in humanitarian assistance: perceptions, gaps and challenges

Corruption is a threat to the purpose of humanitarian assistance. Until fairly recently, humanitarian assistance has not been considered an important arena in broader efforts aimed at curbing corruption, and corruption has not always been considered a particularly important concern for humanitarian assistance despite the obviously challenging nature of the context of humanitarian emergencies. Corruption, though, is a threat to humanitarian action because it can prevent assistance from getting to the people who most need it, and because it can potentially undermine public support for such assistance. This paper examines perceptions of corruption and its affects, documents best practices, and outlines gaps in understanding. It suggests recommendations for improving the capacity of humanitarian agencies to prevent and manage the risk of corruption. Agencies have taken steps to combat corruption and improve accountability--downwards and upwards--but scope remains for improvement and for greater sharing of learning and good practice.     

Global factors shaping the future of food aid: the implications for WFP

Food aid is a key component of a humanitarian response but its use in other programming contexts is subject to numerous criticisms. Even in humanitarian emergencies food aid is often late, unreliable and out of proportion to other elements of the response. Three major factors will shape the future of food aid. First, mechanisms of food aid governance are being reviewed and may undergo major changes—particularly the Food Aid Convention now that hopes have diminished for an Agreement on Agriculture at the World Trade Organisation. The second significant factor is donor agency trends. Overall levels of food aid have dropped fairly steadily in recent decades and there are several discernible trends in resource allocation, procurement and the use of food aid. The third factor is an emerging body of best practice that will define acceptable standards of food aid programming in the future.     

The application of geographic information systems and global positioning systems in humanitarian emergencies: lessons learned,programme implications and future research

Geographic information systems (GIS), global positioning systems and remote sensing have been increasingly used in public health settings since the 1990s, but application of these methods in humanitarian emergencies has been less documented. Recent areas of application of GIS methods in humanitarian emergencies include hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and programme integration; and programme monitoring and evaluation. The main use of GIS in these areas is to provide maps for decision-making and advocacy, which allow overlaying types of information that may not normally be linked. GIS is also used to improve data collection in the field (for example, for rapid health assessments or mortality surveys). Development of GIS methods requires further research. Although GIS methods may save resources and reduce error, initial investment in equipment and capacity building may be substantial. Especially in humanitarian emergencies, equipment and methodologies must be practical and appropriate for field use. Add-on software to process GIS data needs to be developed and modified. As equipment becomes more user-friendly and costs decrease, GIS will become more of a routine tool for humanitarian aid organisations in humanitarian emergencies, and new and innovative uses will evolve.     

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.     

Nutritional response to the 1998 Bangladesh flood disaster: Sphere minimum standards in disaster response

In this study we use a cross-sectional survey to evaluate the nutritional response to the 1998 Bangladesh Flood Disaster by 15 relief agencies using standards developed by the Sphere Project. The Sphere Project is a recent attempt by agencies around the world to establish universal minimum standards for the purpose of ensuring quality and accountability in disaster response. The main outcomes measured were resources allocated to disaster relief types of relief activities and percentage of agencies meeting selected Sphere food aid and nutrition indicators. Although the process of nutritional response was measured, specific nutritional and health outcomes were not assessed. This review found that self-reported disaster and nutritional resources varied widely between implementing agencies, ranging from US $58,947 to $15,908,712. The percentage of resources these agencies allocated to food aid and nutritional response also varied, ranging from approximately 6 to 99 per cent of total resources. Agencies met between 8 and 83 per cent of the specific Sphere indicators which were assessed Areas in which performance was poor included preliminary nutritional analysis; beneficiary participation and feedback; disaster preparedness during non-emergency times; monitoring of local markets and impact assessment. Agencies were generally successful in areas of core humanitarian response, such as targeting the vulnerable (83 per cent) and monitoring and evaluating the process of disaster response (75 per cent). The results here identify both strengths and gaps in the quality of humanitarian response in developing nations such as Bangladesh. However, they also raise the question of implementing a rights-based approach to disaster response in nations without a commitment to meeting positive human rights in non-disaster times.     

Humanitarian information systems and emergencies in the Greater Horn of Africa: logical components and logical linkages

Natural and man-made emergencies are regular occurrences in the Greater Horn of Africa region. The underlying impoverishment of whole populations is increasing, making it more difficult to distinguish between humanitarian crises triggered by shocks and those resulting from chronic poverty. Shocks and hazards can no longer be seen as one-off events that trigger a one-time response. In countries that are both poor and exposed to frequent episodes of debilitating drought or chronic conflict, information needs tend to be different from the straightforward early warning/commodity accounting models of information systems that have proven reliable in past emergencies. This paper describes the interdependent components of a humanitarian information system appropriate for this kind of complex environment, noting the analytical links between the components and operational links to programme and policy. By examining a series of case studies from the Greater Horn region, the paper demonstrates that systems lacking one or more of these components will fail to provide adequate information--and thus incur humanitarian costs. While information always comes with a cost, the price of poor information--or none--is higher. And in situations of chronic vulnerability, in which development interventions are likely to be interspersed with both safety nets and emergency interventions on a recurrent basis, investment in improved information is a good investment from both a humanitarian and a financial viewpoint.     

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.