~Written by Victoria Stanford (Contact: email@example.com)
World Humanitarian Day on August 19th marks an opportunity to reflect on the current status of the global humanitarian system. Its workforce, resources and budgets have been pushed further than ever before in the face of increasingly complex and protracted crises. Health partners are currently responding to sustained crises in 32 countries, with the total number of people targeted to receive assistance reaching 74.9 million as of March 2015 (WHO, 2015 (i)). The scope of humanitarian response is therefore obligated to expand and adapt in response to its high-volume demand. Increasingly this means agencies need to include not only emergency relief, but also long-term capacity building and development support into their mandates (SOHS,2015). The nature of humanitarian response is in transition; it is no longer a “stop-gap” between crisis and recovery, but now also forms a significant part of crisis prevention and resistance in disaster-prone settings (OCHA,2015). The system now also involves a multitude of actors, including NGOs-international, local and regional, supranational agencies and even private sector partners. Unsurprisingly, this means the humanitarian system today requires more meaningful collaboration between its various partners which will depend on defining leadership, identifying accountability and ensuring quality.
An evidence-based culture
One of the ways in which these necessary improvements to the system could be achieved is to address its information-base. Information, evidence and data both used by and reported from the humanitarian system should be assessed for its gaps and inadequacies, enabling the system actors to understand the breadth and nature of the crisis they are responding to (Thieren, 2005). Evidence seems an ambiguous and uninspiring concept, one which does not comfortably fit with the misleadingly gung-ho image of the humanitarian sector and its workforce. Despite this, there seems to be an encouraging shift in mind-set within the system; there is a growing appetite for more academically-driven crisis responses which rely on a culture of evidence (Bantavala, 2000). Instead of ad-hoc policies based on individual NGO mandates and values, there is the desire to see a more co-ordinated approach to, particularly, health assistance which relies on useful information collected in a scientific manner, as for any field of study (Robertson, 2002). The effect of not providing good-quality, robust and accurate data is that aid policies, interventions and practices are left unevaluated. The danger here is that this leads to poor representation (often with underestimation) of the extent and nature of population need, and therefore uncertainty about how to provide assistance (Toole, 2001). Even more worrying is that “poor information on a problem is often interpreted to mean that a problem is unimportant” (Murray, 1996). Lacking credible evidence therefore creates a vulnerability for the humanitarian system when it needs to advocate on behalf of in-need populations for support from often unwilling or budget-bound governments and supranational agencies.
Introducing evidence into the humanitarian system
The concept of building an information-base of evidence procured by programme and intervention evaluation is not novel to the humanitarian system. The Joint Evaluation of Emergency Assistance to Rwanda (JEEAR) established in the aftermath of the 1994 genocide was the first system-wide, multinational, multi-donor evaluation, setting a precedent for recognising accountability in humanitarian assistance, largely by incorporating better information management and dissemination (Eriksson, 1996). In much the same way, the SPHERE Guidelines were also developed in answer to the failure of the humanitarian system to adequately respond to this same crisis (Buchanan-Smith, 2003). These guidelines were used to set out key concepts of quality control and ‘core humanitarian standards’ to reign in non-uniformity which leads to discrepancies in intervention performance and effectiveness. However this uniform “best practice” approach has been fiercely criticised by leading agencies such as Doctors without Borders (MSF) who lambasted the SPHERE protocols for discouraging contextualisation, creativity and flexibility (Orbinski,1998). Other initiatives such as ReliefWeb have also attempted to contribute to a growing information-base by creating a publically-available database system which allows individual agencies to report their programmes and outcomes. This and similar efforts however have been limited by a lack of responsible participation and resistance of academics to report findings before submitting for journal publication (Mills,2005). Nevertheless, certain systems exist which have been widely used that aim to provide data and evidence in emergency and crisis settings which should be acknowledged here, furthering the argument that an information-base is critical to the strengthening of the humanitarian response.
The information-base: EWARN and Health Information Systems
The EWARN is a surveillance system which collects information on epidemic-prone diseases, using data analysis and statistics to initiate prompt public health responses. The subsequent statistical picture is disseminated to appropriate agencies to set about prioritising and planning interventions (WHO 2015 (ii)). The EWARN has shown promise in South Sudan where the multi-partner style of data collection and management (using the WHO as a lead agency) means reporting to a central system creates a more timely and efficient response. In 2002 this was used during a suspected viral haemorrhagic fever outbreak and successfully side-stepped disaster (WHO, 2002). Also in countries such as Iraq, the EWARN functions well where the leading agency work closely with the domestic Ministry of Health to optimise the existing surveillance systems and incorporate them into the larger, more co-ordinated picture. This however means that i) an agency has to have the will and necessary legitimacy to take on leadership responsibilities and ii) the crisis in itself needs to be recognised internationally in order to attract actors with sufficient skills and resources to respond to the collected evidence. Further obstacles occur in particularly complex crises such as in Syria, where domestic surveillance systems are disrupted and the reach and physical capabilities of humanitarian agencies in the field is limited (Mala, 2014). Yet along with its various implementations issues, the EWARN in itself lacks the breadth that may be required of an evidence-collecting system within complex emergencies or long-term crisis support, where epidemic control is not the main, or even primary objective.
Health Information Systems (HIS)
Many large humanitarian agencies have created internal methods of building an evidence-base to guide planning which collect health data in a more integrated manner than the emergency-specific EWARN. The Health Information System (HIS) as a concept is not specific to the humanitarian system. An HIS aims to provide good quality data and its subsequent analysis and dissemination about the health sector, allowing evidence to directly underpin decision-making (WHO, 2008). The UNHCR is a particularly prudent example of an aid agency which has adopted and adapted the HIS for the crisis setting-with relative success. The UNHCR HIS operates on a large scale, collecting data from over 90 camps in over 20 countries (personal research of the UNHCR HIS Twine Application) and providing monthly reports on the status of various essential health indicators. Figure 1 shows the June 2013 report from Gasorwe refugee camp in Burundi. As is shown, the health indicators are compared between camp and national populations which is an essential comparison to make as it allows population-specific intervention. This disaggregation in populations is even more necessary given that protracted crises often see emergency-phase camps become long-term settlements where the health needs of the refugee and host populations overlap (Feldman, 2007)
The UNHCR HIS however has a number of failures, most notably that it only exists within post-emergency camps which by definition are stable and therefore health status is generally better than newer camps. Also, only those who are registered with the UNHCR are included in statistics and therefore the most vulnerable groups of refugees, particularly internally displaced persons (IDPs) are not included in statistics, leading to misrepresentation of the scale of the problem and increases the likelihood of ignoring a significant amount of human need. In essence, the HIS can provide an excellent framework for the health indicator-based, disaggregated information-base that humanitarian agencies should attempt to create on a system-wide basis. Yet, creative collaboration is required to ensure that high quality data and evidence can be collected from all contexts, in a standardised way that allows inter-agency data exchange and collective responses.
To put it simply, the EWARN and HIS are used here to illustrate that the humanitarian system has already acknowledged the need to use evidence to monitor population need and thus plan response, although efforts are currently inadequate. What is now required is a system-wide, scientific evaluation of the use of evidence as a guide for action in crisis and disaster settings, in order to legitimise humanitarian work on a global scale and safeguard it from opposing forces.
Concluding thoughts: deciding on outcomes
Optimising and prioritising evidence with the aim to strengthen the humanitarian system may force us to reflect on what should be considered as end-points. The outlook that governs public health initiatives can arguably be too consequentialist; they are based on success rates, outcomes and units of ‘effect’ (Robertson, 2002). It could be argued that humanitarianism by its very definition should adhere to a more human-rights based approach that focuses on duty and responsibility. With the increasing burden of human need, the humanitarian system must decide how it will approach new contexts, persisting barriers and emerging challenges such as climate change and the urbanisation of displacement with appropriate credibility and inter-agency consistency that can deliver powerful, effective humanitarian action.
Banatavala,N and Zwi,A (2000) Conflict and health Public health and humanitarian interventions: developing the evidence base, BMJ, 321:101–5.
Buchanan-Smith, M. (2003). How the Sphere Project Came into Being: A case study of policy-making in the humanitarian aid sector and the relative influence of research. Overseas Development Institute.
Eriksson J (1996) The International Response to Conflict and Genocide; Lessons from Rwanda, Synthesis Report; Joint Evaluation of Emergency Assistance to Rwanda.
Feldman S (2007) Development assisted integration: a viable alternative to long-term residence in refugee camps? The Fletcher Journal of Human Security, Vol 22:49-68.
Mala P and Ghada M et al (2014) Establishment of the EWARN system for the Syrian crisis: experience and challenges, 16th International Congress on Infectious Diseases: Infectious Disease Surveillance Abstract No.53042; Cape Town, South Africa.
Mills J (2005) Sharing evidence on humanitarian relief, BMJ, 331:1485.
Murray,C and Lopez,A et al (1996) Evidence-based health policy-lessons from the Global Burden of Disease study, Science, 274(5288), p.740.
OCHA (UN Office for the Co-ordination of Humanitarian Affairs) (2015) OCHA in 2014 &2015 Plan and Budget [Online] Available at: https://docs.unocha.org/sites/dms/Documents/OCHA%20in%202014-15%20vF%2072%20dpi%20single%20WEB.pdf[Accessed 6 August 2015]
Orbinski J (1998) On the meaning of Sphere standards to states and other humanitarian actors, Lecture delivered December 3 1998; London.
Robertson D, Bedell R et al (2002) What kind of evidence do we need to justify humanitarian aid? The Lancet, 360:330-33.
SOHS (State of the Humanitarian System), State of the Humanitarian System, ALNAP, Progress Report 2015, April 2014 [Online] Available at: http://www.alnap.org/resource/20489.aspx [Accessed 6 August 2015]
Toole MJ, Waldman RJ & Zwi AB (2001) Complex humanitarian emergencies. In:International PublicHealth, Aspen Publishers, Gaithersburg, pp. 439±500.
Thieren, M. (2005). Health information systems in humanitarian emergencies.Bulletin of the World Health Organization, 83(8), 584-589.
WHO (2002) Weekly Epidemiological Record; Early warning response and surveillance network (EWARN):Southern Sudan, 25 January 2002.
WHO (2008) Health Informaiton Systems; WHO Toolkit.
WHO (2015) (I) WHO Humanitarian Response: Summary of health priorities and WHO projects in interagency strategic response plans for humanitarian assistance to protracted emergencies, April 2015 [Online] Available at: http://reliefweb.int/report/world/2015-who-humanitarian-response-summary-health-priorities-and-who-projects-interagency [Accessed 4 August 2015]
WHO (2015) (II) Early warning systems; emergencies preparedness and response [Online] Available at: http://www.who.int/csr/labepidemiology/projects/ewarn/en/ [Accessed 10 August 2015]