The humanitarian system is not just broke, but broken: recommendations for future humanitarian action

Article published on The Lancet website on 06/08/2017 by Professor Paul B. Spiegel

An unprecedented number of humanitarian emergencies of large magnitude and duration is causing the largest number of people in a generation to be forcibly displaced. Yet the existing humanitarian system was created for a different time and is no longer fit for purpose. On the basis of lessons learned from recent crises, particularly the Syrian conflict and the Ebola epidemic, I recommend four sets of actions that would make the humanitarian system relevant for future public health responses:

• operationalise the concept of centrality of protection;
• integrate affected persons into national health systems by addressing the humanitarian–development nexus;
• remake, do not simply revise, leadership and coordination;
• and  make interventions efficient, effective, and sustainable. For these recommendations to be implemented, governments, UN agencies, multilateral organisations, and international non-governmental organisations will need to put aside differences and relinquish authority, influence, and funding.

This is the fourth in a Series of four papers about health in humanitarian crises

Introduction

An unprecedented number of humanitarian emergencies of large magnitude and duration are taking place, from Syria to South Sudan and Yemen. Protracted situations, often with additional acute emergencies, are becoming the new norm. Refugees and internally displaced persons (IDPs) are at their highest numbers in a generation. Most refugees are not living in camps but in urban or rural areas, and many of them come from middle-income countries. Often overlooked, yet constituting the majority of persons affected by conflict, are persons who are not displaced but rather entrapped in conflict settings, such as those in Syria and Yemen.

Funding appeals to address humanitarian emergencies have increased exponentially from US$12 billion in 2012 to $28 billion in 2015—the largest amount ever recorded.3 However, with only 45% of funding received, 2015 was also the year with the largest financial shortfall.

The humanitarian system consists of a broad and diverse range of actors that traditionally includes governments, donors, multilateral and bilateral agencies, international and national non-governmental organisations (NGOs), community-based organisations, UN agencies, and international agencies such as the International Committee of the Red Cross. The humanitarian system is constantly evolving according to emerging situations. Affected persons and communities must be at the core of the humanitarian system and part of the decision-making process; unfortunately, this is often stated, but not acted upon. 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. In September, 2015, the Sustainable Development Goals were launched with the theme to leave no one behind, but these goals cannot be achieved if more than 65 million forcibly displaced persons and more than 100 million non-displaced persons are not taken into account.

The focus of this paper is public health action in humanitarian emergencies due to conflict, but many of the recommendations are applicable to the entire humanitarian system and to systems for handling natural disasters. The views represent my experience as a senior UN official at the UN High Commissioner for Refugees (UNHCR) in the past decade and as an academic in humanitarian emergencies research. Using lessons learned from recent crises, I suggest four sets of actions that would help to make the humanitarian system fit for future public health responses, particularly the Syrian conflict and the Ebola epidemic in west Africa. These recommendations are not only for humanitarian actors, because they cannot address these issues alone.

Key messages

•The humanitarian system is no longer fit for purpose and needs to be changed.
•The concept of centrality of protection must extend beyond declarations and policies to be operational in the field.
•The development of countries will be negatively affected if humanitarian emergencies are not addressed in a complementary manner with development assistance.
•A major revision of humanitarian leadership and coordination of humanitarian emergencies is needed that has fewer but more competent and operational actors with a clearer command and control leadership structure.
•Conflicts and displacement are increasingly protracted, and policies, funding, and interventions should therefore be developed and implemented for the medium term and long term, despite aspirations for rapid resolution.
•Innovative humanitarian health financing must be actively pursued to expand the types of donors and create new financing instruments.
•The most cost-effective interventions that will help the greatest number of people need to be prioritised; more research into this issue is needed as existing data and guidance are insufficient.

Operationalise the concept of centrality of protection

The failure of the UN to protect civilians in the final stages of the war in Sri Lanka that ended in 2009 led to numerous reviews that underlined the importance of operationalising protection in humanitarian emergencies and set in motion numerous initiatives including the Human Rights Upfront initiative. Yet the concept of centrality of protection is vague to many actors, as are practical ways to implement protection interventions beyond bold declarations and strategies. Unfortunately, the definition of protection, that “all activities aimed at obtaining full respect for the rights of all individuals in accordance with international law—international humanitarian, human rights and refugee law—taking into account their age, gender, social, ethnic, national, religious or other background”4 does little to improve understanding of the concept. The centrality of protection encompasses human security, which moves the focus away from traditional state-centric ideas of security to the security of individuals, which includes their protection and empowerment.5 In other words, 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 health-care providers are trained to respond to gender-based violence and can manage data confidentiality.

Protection of civilians is paramount in conflict. The death of up to 500 000 Syrians since the conflict in Syria began in 2011 is horrifying. The increasing number of deliberate attacks on health-care workers and facilities, particularly in Syria and Yemen, is a disturbing new trend that goes against centrality of protection.6, 7, 8 Physicians for Human Rights have documented more than 360 attacks on about 250 medical facilities and the deaths of more than 730 medical personnel in the Syrian conflict.9 Thus, the unanimous UN Security resolution on May 3, 2016, to strengthen protection for health-care workers, sick and wounded people, hospitals, and clinics in war zones is welcome.9 However, given the lack of political will by the Security Council to address the root causes of the Syrian war and other conflicts, how the resolution will translate into tangible results remains uncertain. Once again, laws and resolutions are important and must serve as the basis for action, but without substantial consequences of breaking them, they remain only words on paper.

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 specialise 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. The responses to the AIDS and Ebola crises are excellent examples of how, after an initial period of protection-insensitive responses, protection and health actors were able to work together to practically integrate protection principles into what initially were primarily medicalised responses and thereby improve outcomes. For example, restricting movement and declaring quarantine areas during widespread epidemics do not work and could perversely increase transmission as people might evade authorities. After a difficult beginning to the Ebola epidemic, working with communities to allay their fears, understanding and responding to their behaviours, and providing a secure environment for them to voluntarily declare possible signs and symptoms of Ebola virus infection and seek support was essential in addressing the epidemic.

In summary, to operationalise the concept of centrality of protection: (1) interpret centrality of protection in an inclusive manner where health interventions are considered basic life-saving protection interventions, while ensuring such health-care services are protection-sensitive; (2) 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; and (3) do not restrict population movements nor undertake mandatory testing in humanitarian emergencies except under exceptional circumstances.

Integrate affected persons into national health-care systems by addressing the humanitarian–development nexus

The humanitarian–development gap has been recognised as a major challenge for decades. How can humanitarian action transition into long-term development, and how can development actors implement resilient programmes that prepare communities for future emergencies? In part due to the complexities of the Syrian crisis and the fragility of countries that constantly experience humanitarian emergencies, humanitarian actors are working more closely with development actors than ever before to translate their different terminologies, business methods, and timelines for response into a language that is comprehensible to both sides. Furthermore, collaboration with the private sector is becoming increasingly common. Some donors (eg, Canada, the UK) have merged their humanitarian and development offices into one agency, and other donors, such as the European Union and the USA, should strongly consider doing the same. If donors have different and separate streams of funding for humanitarian and development responses, actors’ interventions will clearly not be complementary.

The economic and social effects of refugees on national host economies has not been rigorously studied. However, some development-focused agencies have begun to undertake such research and change their policies. The World Bank has analysed how forced displacement affects development and local economies.10 The results have helped to break down stereotypes and show a nuanced reality. Assuming that the investment climate is sound, the presence of refugees and IDPs typically increases demand and creates jobs, while increasing the labour force. In April, 2016, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria approved their 2017–22 strategy, which, for the first time, places fragile contexts as an important part of their work. It also approved its first policy on fragile contexts, entitled The Global Fund in Challenging Operating Environments.11 This change in policy, combined with the introduction of an emergency fund in 2014, has allowed the Global Fund to rapidly finance activities in a variety of complex humanitarian emergencies, including the Syrian and Ukrainian conflicts and the Ebola crisis in Sierra Leone.

Creating alternatives to camps, if done well, should allow refugees and 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 health-care strategies should take into account where the affected displaced populations should be or are located. The establishment of parallel health-care 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; this applies to camp and non-camp settings. 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; this master plan concept seeks to anchor the displaced persons’ presence within the broader context of national and local development, services, infrastructure, society, and the economy. Existing national health-care 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 health-care services need to be provided to affected populations during the acute phase of the emergency.

Addressing the humanitarian–development nexus also means dealing with important issues of mandate versus needs. 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. Humanitarian organisations dealing with displaced persons have long prioritised such people according to legal and institutional categories, primarily focusing on those fleeing conflict, violence, or persecution. However, the approach to addressing the humanitarian dimension of migration should be more inclusive, regardless of status.12 Health-care access and quality should meet minimum international standards (eg, Sphere Project) for all affected persons. This minimum level of health-care services for forcibly displaced persons becomes an ethical issue when surrounding nationals are also not receiving minimal levels of services. Examples exist of refugees receiving better health-care services than IDPs and nationals (eg, Chad, Cameroon, and many other protracted settings).13, 14 This disparity occurs when parallel services are provided to persons according to status or when donors earmark funding for specific populations. Overall, this can be avoided if health-care services for refugees and IDPs are integrated into existing national services.

Although all persons in a specific geographic area should have equitable access to a similar level and quality of health-care services, irrespective of status, there are differences in terms of legal rights, international law, choices, and coping mechanisms according to the status of affected persons, and these differences need to be factored into the design of programmes. Nationals and IDPs are citizens of a country and will generally have access to national services at a favourable price, unlike economic migrants or refugees, who might only have access to some health-care services, often at higher prices. Nationals and IDPs might also have access to social safety nets, financial services (eg, bank accounts or social services), and employment opportunities that might not be available to non-nationals. Different groups of people might have similar needs, and the moral responsibility to address them is the same, but different entities have been established to deal with different groups. The challenge is to bolster a non-discriminatory approach without affecting standards (ie, not to move towards the lowest common denominator), speed of response, humanitarian principles and space, and accountability for results.

A summary of recommendations for integrating affected persons into national health-care systems by addressing the humanitarian-development nexus includes: (1) take into account existing development health-care strategies for the district or region where the conflict-affected population is located when developing humanitarian preparedness plans and in the response; (2) integrate affected populations into national health-care systems and avoid establishing parallel health-care services except in situations where existing systems cannot be quickly capacitated to respond, when humanitarian principles cannot be upheld, or security reasons are paramount; (3) compensate for the temporary disruption of national cost-recovery systems as free health-care services are provided to affected populations during the acute phase of the emergency; and (4) make equitable access to quality health-care services available to all persons in a specific area regardless of status while considering important differences in terms of legal rights, international law, choices and options, and coping mechanisms according to status of affected persons.

Remake, do not simply revise, leadership and coordination

Leadership and coordination of humanitarian emergencies have become too complex and process-oriented in the past decade. Numerous humanitarian restructurings have been attempted to improve the effectiveness, efficiency, and accountability of the humanitarian response: the Sphere Project was created after the 1994 Rwanda genocide,14 the Cluster Approach and the enhanced Central Emergency Response Fund were established after the 2003 Darfur crisis and the Indian Ocean tsunami of 2004, and the Transformative Agenda was implemented after the 2010 Haiti earthquake. However, 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.15, 16 Some of the new actors in the Syrian situation, such as non-traditional donors, national and local NGOs, the private sector, and capable governments, have capacities but might not wish to accept or follow certain humanitarian principles or existing norms. Other changes include increasing interconnectivity through the internet and social media and through market-based programming and cash transfers.16, 17 Coordination has become a means to an end. Perhaps the UN Office for Coordination and Humanitarian Affairs’ mantra of “coordination to save lives”18 should be changed to “minimal, efficient, and context-specific coordination, with fewer processes and meetings, that leads to differentiated and effective responses and saves lives”—less catchy, but more accurate. What is becoming clear, however, is that the complexity and diversity of humanitarian emergencies require a different leadership style and alternative coordination models than what are used in the existing centralised and bureaucratic system, with its financial, regulatory, and cultural barriers.16, 19 A more customised approach delivered in varying combinations with the ability to flexibly scale up and down is needed rather than the current set package (panel).17

Panel

Coordination and response scenarios according to capacity and respect for humanitarian principles

Scenario 1

A capable government that respects humanitarian principles should work with capable national humanitarian and development non-governmental organisations (NGOs) and community-based organisations to address the humanitarian situation and ensure that it becomes a win–win situation for the conflict-affected populations and for the medium-term and long-term development of the country. In this scenario, international donors should ensure that their humanitarian and development offices work together (or better yet, be part of one unified system) to have complementary policies, programmes, and funding components. In this scenario, the operational UN agencies and international NGOs will provide strategic and technical assistance and fill gaps in assistance. This scenario will increasingly become the norm as governments and national non-governmental and community-based organisations increase their capacity.

Scenario 2

When the government and national non-governmental and community-based organisations respect humanitarian principles but do not have the capacity to coordinate and respond sufficiently, the UN agencies and international humanitarian and development NGOs must take a leading role, similar to their role today. Consequently, an increased proportion of the funding, as occurs at present, will be provided to them. However, the emphasis on improving the capacities of governments and local non-governmental and community-based organisations should be strengthened.

Scenario 3

Governments or local humanitarian non-governmental and community-based organisations might have sufficient capacity to address the situation, but they do not respect humanitarian principles. In this case, UN agencies and international humanitarian and development NGOs should take leading and independent roles.

Despite the improving competencies of governments and national NGOs, some large-scale emergencies will still need a large international presence. Coordination by consensus and provision of space to all agencies who wish to respond do not work in large-scale emergency responses. There needs to be a limited number of operational agencies that have authority to intervene and can be held accountable. In my view, the most operational agencies in the UN system are the World Food Program, UNHCR, and UNICEF. These three organisations should be tasked to respond to complex emergencies. The same principle applies to international NGOs, some of whose mandates have become so broad that they have lost the focused, sectoral expertise to respond to emergencies effectively. Technical capacity for emergency settings seems to be decreasing in certain sectors such as health care and water, sanitation, and hygiene (WASH).15 Médecins Sans Frontières remains one of the few international humanitarian agencies that concentrates primarily on the health-care sector and does not rely on a cumbersome coordination system that prioritises process over outcome. As with UN agencies, a limited number of operational international NGOs with the appropriate technical capacities according to context should respond to large-scale emergencies to increase overall effectiveness. 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.

As stated in the Grand Bargain at the World Humanitarian Summit in May, 2016, the reliance on governments and national NGOs should become more predominant in the future.19 Only 0·2% of international humanitarian assistance was reported to have been channelled directly to local and national NGOs in 2014, which is half the amount of funding that was donated in 2012.3 An increase of 25% in humanitarian funding was pledged to local and national responders by 2020 at the World Humanitarian Summit.20 Thus, traditional roles of the UN and international NGOs in many future humanitarian emergencies are likely to evolve into complementary roles in preparedness and contingency planning, capacity building, technical support, protection monitoring, and advocacy. Such an evolution will require the UN and international NGOs to voluntarily relinquish responsibility, influence, and funding, which will not be easy and must be monitored closely. Similarly, donors may not be able to demand the same level of detailed and cumbersome reporting or financial accountability from these governments, national NGOs, and community-based organisations as they do from the UN and international NGOs at present, which might be difficult for these donor countries to accept politically. However, when governments are part of the conflict, the international community’s role in protection, delivery, and advocacy remains crucial, as is the case currently in the conflicts in Syria and South Sudan.

WHO has shown unsatisfactory leadership and coordination of health-care sector preparedness and response in humanitarian emergencies. WHO is mandated to lead the Global Health Cluster, the humanitarian system’s mechanism for coordinating health-care responses to humanitarian emergencies in non-refugee settings; to support crisis preparedness and response; to provide surge capacity; to establish and disseminate technical standards; to enforce international health-care regulations; and to report attacks on health-care workers.21 In practice, WHO remains more of a normative than operational agency. It works closely with Ministries of Health and has been loathe in the past to openly speak out about health emergencies without approval by governments. The recent Ebola crisis is only the latest of a series of examples in which politics has trumped evidence and public health. Other factors that contribute to WHO’s underperformance in emergencies include a heavy bureaucracy in which regional politics dominate central decision making, senior positions appointed out of political considerations rather than merit, insufficient core funding and central emergency funds, and lack of accountability. For more than a decade, WHO has gone through successive reforms and restructuring of its humanitarian and epidemic divisions. WHO’s poor performance at the beginning of the Ebola crisis led to another large organisational reform following recommendations by numerous external and internal panels.21 Many important changes have already occurred at WHO, including the merger of the humanitarian and health security departments, the creation of an independent oversight advisory committee, the expansion of the WHO contingency fund for emergencies, and increased centralisation of authority and accountability for emergencies. However, WHO cannot and should not be expected to undertake this reform and respond to health emergencies alone; it needs to take advantage of the capacities of other organisations where there is a comparative advantage, which means forfeiting some power, authority, and funding to others. It also means that these other agencies need to step up and ensure that they have the capacity for what they promise to do. It is still unclear whether WHO’s leadership, member states, regional bodies, and donors will allow such far-reaching reforms to suceed. This should be WHO’s last opportunity to become the leader and coordinator of health preparedness and response in humanitarian emergencies that we all wish it to become. Should this reform fail, then a new body or an existing multilateral agency must take its place.

A summary of recommendations for remaking and not simply revising leadership and coordination include:(1) undertake 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; and (2) monitor closely WHO’s humanitarian reform process to ensure that fundamental changes are continued to be made to allow it to become an independent and operational agency that leads the health-care sector in humanitarian emergencies. If WHO is not able to meaningfully reform to be the leader of the health-care sector in humanitarian emergencies, another existing multilateral agency or a new agency should be created.

Make interventions 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 organisations are now expected to deal with social safety nets, livelihoods, and people’s wellbeing in protracted settings for decades. Realistic expectations on what humanitarian action can and should achieve must be agreed upon. However, much more can be done to improve efficiencies and effectiveness and to ensure sustainability of humanitarian interventions. Data and research will be indispensable. Many of these transformations were stated in a far-reaching report, entitled Too important to fail—addressing the humanitarian financing gap,19 and were agreed to in the Grand Bargain at the World Humanitarian summit in 2016.

Recognising that protracted situations are becoming the norm, the need for long-term investment in sustainable systems and infrastructure in areas such as health care, WASH, and education is becoming clear but remains politically sensitive for host governments and requires long-term considerations and financial commitments from donors. In 2014, 6·4 million refugees (45% of all refugees under UNHCR’s mandate) in 26 countries had been a refugee for at least 5 years.1 In 2014, humanitarian assistance became the UN’s costliest activity, surpassing peacekeeping by $2 billion,3 with protracted crises the single biggest driver of these spiralling costs. Up front investments, such as establishing water and sanitation systems in settlements and camps, will pay off in the long term provided there is a recognition that refugees are likely to reside in a location for many years. Projects are underway to estimate the costs of establishing long-term WASH facilities, including the use of hybrid generators for water pumps in refugee camps and amortising them over 10–15 years. Whenever possible, camps should be avoided and services for refugees and IDPs should be integrated into national health-care systems. Furthermore, multiyear committed funding is needed for humanitarian organisations to work within the government health-care development plans and with development actors to ensure that affected persons will be able to integrate into national health-care systems when feasible. The inefficiencies of providing humanitarian funding on an annual basis with no commitments to continued funding for long-term projects are large and wasteful.

Different models of innovative health financing, such as social impact financing and health insurance, need to be explored in humanitarian settings. The Ebola outbreak in west Africa pushed the world to react differently in future pandemics. Pandemic bonds, similar to catastrophe bonds for natural disasters, are being created by the World Bank, as is a Global Financing Facility. Pandemic bonds and insurance are part of a growing list of financial instruments that will allow commercial capital to be invested in humanitarian and development targets. The insurance industry and multilateral development banks are also moving into risk financing, such as sovereign risk financing, agricultural insurance, and social protection.19 The African Risk Capacity was established as a specialised agency of the African Union. Its mission is to use modern finance mechanisms such as risk pooling and risk transfer to create pan-African climate response systems that enable African countries to meet the needs of people harmed by natural disasters. The UNHCR and its partners are already using health insurance and other existing government social safety net programmes 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.

Beyond funding, efficiencies in humanitarian action can be enhanced by taking advantage of innovation, technology, and partnerships with the private sector. Nowhere is this more promising than with cash-based transfers.22 Cash-based transfers are under utilised and can be substantially scaled up and used more systematically to provide increased dignity and choice to affected populations, improve efficiencies to aid provision, and support local economies.23 Multipurpose cash transfers (providing unrestricted cash transfers to persons and families to cover a certain portion of their needs according to their choice and prioritisation) will become particularly important in this age of information technology and expanding private sector partnerships. Evidence exists particularly for the scaling up of such interventions for food security.23 Further research of cash-based transfers needs to be undertaken in the health-care and education sectors as they are different to those of commodities because systems, infrastructure, and trained personnel are needed to provide such services. More attention on how persons receive and use remittances in humanitarian settings is also needed to reduce the cost of such transfers.

The use and limited availability of data and research to improve efficiencies and effectiveness in humanitarian emergencies is not new. In another paper in this Series, Blanchet and colleagues24 report the results of a systematic review of evidence on public health interventions in humanitarian crises. Only 345 studies between 1980 and 2014 met their criteria, with a quarter of studies related to communicable diseases, 22% of studies were about nutrition, and only 2% addressed non-communicable disease. In another paper in this Series, Checchi and colleagues25 argue that although various methods exist to measure public health risks and services in crisis settings, many of these methods do not have a strong evidence base. The Syrian crisis and the Ebola epidemic highlight the need for and importance of data and its transparent use, pre-approval for studies by ethical review boards, rigorous and practical evidence-based methods to identify vulnerable households and persons who need protection and assistance, and technology to achieve results.

A summary of recommendations for making interventions more efficient, effective, and sustainable include: (1) provide upfront investment by donors in health-care and WASH infrastructure at the beginning of an emergency recognising that refugees and IDPs will likely be in protracted settings; (2) initiate multiyear funding for health, nutrition, and WASH-related activities to allow for sustainable interventions that will improve integration into national health-care services; (3) actively and systematically scale up cash-based transfers in humanitarian emergencies following context-specific assessments; (4) undertake research on conditional and unconditional cash-based transfers as well as remittances for health care, WASH, and nutrition interventions in humanitarian emergencies to build up the evidence base and provide future guidance; (5) explore different health-care financing models for humanitarian emergencies such as pay for success financing and other social impact bonds as well as health insurance; and (6) 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.

Conclusion

The current humanitarian system was created for a different time. The recent crises, exemplified by the unprecedented level of forced displacement in a generation, the Syrian crisis and its spill over into Europe, and the Ebola epidemic in west Africa, have highlighted failures of a system that have been evident for some time. Major changes to the system will require operationalising 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 UN, and international organisations will need the political will to relinquish authority, influence, and funding.

Declaration of interests

I have been the Director of the Johns Hopkins Center for Humanitarian Health since July, 2016, and I am Chair of the Funding Committee for Research for Health in Humanitarian Crises. I was Chief of the Public Health Section and then Deputy Director of the Division of Progamme Support and Management at UNHCR between 2004 and 2016. The views in this paper represent mine alone and do not represent the organisations that I have worked for.

Acknowledgements

The views and opinions expressed in this paper are those of the author and do not necessarily reflect those of the organisations for which he has worked or work. I thank Theresa Beltramo, Emanuele Capobianco, Arafat Jamal, and Chris Lewis for reviewing drafts of this paper.