Introduction

Humanitarian emergencies capture the public's attention. Television images and newspaper stories convey scenes of civilians fleeing violence or the devastating and indiscriminate impact of natural disasters and depict the life-saving interventions of health professionals.

Behind these public images of humanitarian action lies a complex machinery of multilateral agencies, trans-national non-governmental organizations, donor governments, and national-level agencies. While these organizations are united by the objective to alleviate suffering and improve population health, humanitarian groups’ interactions are not without acrimony or debates regarding effectiveness.

Key debates include how to enhance the professionalism of humanitarian personnel; how to increase coordination and collaboration among international and national groups without undermining humanitarian principles of independence and neutrality; the role of the military and private security firms in humanitarian action; and how to increase efficacy of humanitarian response in diverse operational environments, such as urban settings.

The active engagement of humanitarian professionals in applied research is critical to addressing these debates and improving the humanitarian response. The Harvard Humanitarian Initiative's (HHI) Humanitarian Action Summit, held in 2010 on March 4-6, exemplifies such engagement. The Summit attracts practitioners currently active in humanitarian settings, together with researchers and government officials. The Summit is unique, combining expert presentations with the creation of working groups where participants collaborate to share and develop solutions to overcome challenges. Working groups continue their activities between Summits, facilitating ongoing collaboration and professional development among participants.

HHI's Working Groups

Evaluations of major humanitarian responses, from Rwanda to Haiti, have pointed to the lack of professionalism among many humanitarian personnel as a key impediment to more effective humanitarian action. Many humanitarian personnel lack adequate training on how to provide emergency assistance and have little knowledge of humanitarian norms or standards. The HHI working group on Professionalizing the Humanitarian Response has been active for several years. To enhance humanitarian professionalism, they argue that an individual accreditation system is needed to develop a global association of committed, accredited individuals with basic competencies.

The working group on non-government organization (NGO) Security and Staff Protection examines physical risk for humanitarian workers, acknowledging that while some deaths and injuries are a result of deliberate targeting, others are the result of humanitarian workers being bystanders in dangerous environments. The working group will continue to analyze mechanisms to compile and share security information and examine variance in casualty rates across organizations and humanitarian settings.

The Urbanization and Humanitarian Emergencies group analyzes how to effectively address the needs of the humanitarian population in urban environments. Cities present many challenges to humanitarian response including security, how to identify and differentiate the humanitarian population from the host population, the generally poor living conditions in many urban areas, and how existing humanitarian norms and standards can be translated for urban areas. This group is adapting the Sphere Guidelines to urban settings as well as systematically examining the coordination and security challenges of working in these environments.

The group on Field Level Coordination Among Civilian and Military Humanitarian Actors works to identify and describe effective coordination techniques. They will examine how to institutionalize best practices while recognizing the constraints of the constant turnover of military staff and humanitarian personnel. The working group on Humanitarian Technologies, Crisis Mapping and Challenges in Information Management discusses how to harness the use of these technologies in the humanitarian response.

The group on Surgical Issues in the Humanitarian Space assesses the critical need for surgical expertise in humanitarian settings, but notes that the majority of surgical needs are a result of non-conflict related causes. Another working group on Mental and Psychosocial Support in Crisis and Conflict examines and identifies key knowledge gaps regarding mental health in emergency settings. Their work is guided by the principle of no mental health survey without service and no service without a survey.

The Summit also announced the formation of future Working Groups including a group on Post Conflict Health System Reconstruction which will examine if and how humanitarian personnel can better support national capacities and interface with the local health system. The working group on Clinical Care in the Field will examine how to improve the effectiveness of the clinical component of humanitarian action while another group examines the response of the humanitarian community to food security and hunger.

Throughout the course of the Summit, participants expressed frustration that humanitarian personnel are unable to influence the political decisions that ultimately shape and constrain humanitarian engagement. While the HHI Working Groups can develop guidelines and best practices, the pathways to translate this guidance into action at the international level remain unclear. Research that identifies how humanitarian assistance could be more effective does not find its way into international policy.

Making Policy: Health Diplomacy in Humanitarian Emergencies

The Humanitarian community have been important participants in global processes surrounding technical norms, such as the Sphere Guidelines. However, humanitarian personnel point to critical decisions on humanitarian action that are made in diplomatic forums out of the reach of humanitarian professionals. These forums lack transparency and are not subject to appropriate scrutiny or input from those engaged in the humanitarian response.

While diverse definitions of health diplomacy exist,Reference Feldbaum and Michaud¹ health diplomacy is basically the mobilization of states, international organizations, and non-state persons in response to global health challenges. Although few humanitarian emergencies have an impact on ‘global health,’ the response to these emergencies is global in nature. Natural disasters frequently overwhelm the state, particularly in countries with low capacity. Conflicts either implicate the state, or reflect its fragility. As a result, multilateral agencies and international non-government organizations provide direct health assistance to reduce mortality and morbidity of the civilian population.

As of November 2010, the United Nations Office for the Coordination of Humanitarian Assistance (UN OCHA) estimated that 49 million people required humanitarian assistance.² In 2009, over 15 billion US dollars were dispersed in humanitarian assistance with governments contributing 11 billion US dollars and private contributors 4.1 billion US dollars.³ Health assistance accounts for approximately 10 percent of humanitarian funding.³

Humanitarian action, including health assistance, is characterized by multiple levels of diplomacy. International humanitarian action is governed by global norms and international humanitarian law which includes principles outlined in United Nations General Assembly Resolutions, agreements reached in multilateral forums such as the Inter-Agency Standing Committee and the Geneva Conventions which apply to humanitarian action in war effected countries.

Multiple people engage in health diplomacy at various levels during humanitarian operations. Negotiations determine the amount of assistance, how that assistance is delivered, what personnel are engaged in delivering that assistance, and how to access crisis-affected populations. This diplomacy takes place in multilateral, bilateral and local settings and involves state as well as non-state actors. At the global level, diplomacy plays a role in determining the allocation and scale of resources as well as the technical standards for health interventions. Locally, negotiations determine how assistance is coordinated, the degree to which technical standards and international humanitarian law are upheld, the engagement of the military, and the role of national governments and other national stakeholders.

As a result of this complexity, humanitarian decision-making is opaque. Further analysis is needed to examine diplomacy among those engaged in the delivery of humanitarian assistance including how humanitarian norms govern these interactions and how negotiations affect humanitarian assistance. More research is needed on health diplomacy in humanitarian operations to determine the key decision making forums, those who make these decisions, and the information that shapes the decision making process.

Influencing Diplomatic Processes: Part of the Professionalization Agenda

While the need for research on health diplomacy in humanitarian action is clear, humanitarian actors should not wait for the results of research to take action. To ensure that the voice of humanitarian practitioners is reflected in global humanitarian decision-making, these practitioners need to develop the skills to engage and influence diplomatic processes at both the global and local levels. Needed is training in negotiation and advocacy to influence the decision-making of multilateral organizations among donor and recipient states and among local communities. These skills will enhance the ability of humanitarian actors to achieve their objective of reducing suffering and improving population health. Current efforts to develop professional standards for the humanitarian community should expand beyond technical skills to include training in health diplomacy that enhances the effectiveness of humanitarian action.