The Humanitarian System at a Crossroads: Change or become irrelevant? The Report of the Johns Hopkins Center for Humanitarian Health – Lancet on Health, Conflicts, and Forced Displacement

A Long History of Reform Attempts

Over time, humanitarian action – defined as: “In the context of public health, the set of interventions aimed at mitigating the consequences of crises, due to conflicts, famines, or natural disasters, on morbidity and mortality”¹ – has contributed to saving countless lives and improving the health conditions of affected populations.² 

However, failures have also occurred, often with severe consequences.³ In some cases, humanitarian action has unintentionally strengthened armed groups and fuelled the war economy, contributing to the prolongation of conflicts, as seen in Biafra between 1967 and 1970 and in Ethiopia in 1984.⁴ These failures are partly due to the challenges of operating in chaotic contexts marked by insecurity, political conditioning and manipulation, limited access to populations in need, and insufficient or ineffective funding. However, the shortcomings are not solely attributable to the crisis contexts. Recurring criticisms have also highlighted technical errors, often repeated in different contexts,⁵ due to inadequate preparedness of operators, interventions unsuitable to the context, poor accountability to affected populations, insufficient leadership and coordination, and limited involvement of national and local actors.

Often, it has been these very limitations that have triggered reforms of the humanitarian system, “the rather messy assemblage of humanitarian actors and activities”.⁶ For example, the political and technical failures during the Rwandan genocide⁷ and in the militarised refugee camps of Goma⁸ (Zaire, now the Democratic Republic of the Congo) spurred the development of codes of conduct and minimum standards of assistance^9,10. A new coordination model – the Cluster Approach –, along with the strengthening of the role of humanitarian coordinators and the establishment of a central humanitarian fund, emerged from evaluations of inadequate responses to the crises in Darfur, Sudan,¹¹ and the Indian Ocean tsunami¹² in the early 2000s. Criticisms of the chaotic coordination of humanitarian responses to the earthquake in Haiti and the floods in Pakistan in 2010 contributed to the formulation of the Transformative Agenda, developed under the principles of ‘decolonization’ and ‘localization’ of aid.¹³ In 2016, during the first World Humanitarian Summit in Istanbul, participants committed through the «Grand Bargain» to reform the funding of the sector, allocating a larger share of funds to national and local partners.¹⁴ More recently, the ‘Humanitarian Reset’ and the ‘UN80 Initiative’ represent a response to the cuts in humanitarian aid, aimed at reducing the duplication of mandates among agencies, containing costs, and strengthening the localization of both funding and decision-making processes.^15,16

Despite technical innovations, greater availability of evidence on the effectiveness of certain interventions and the increasing professionalisation of humanitarian actors, many observers agree that the overall balance of humanitarian action remains unsatisfactory.¹⁷ The humanitarian system appears increasingly bureaucratic, unable to adapt to the changed context and pursue the objectives for which it was conceived, based on colonial models, in the aftermath of World War II.^18,19 The complexity of contemporary conflicts, the impunity regarding violations of international humanitarian law, with increasing attacks against civilians, humanitarian workers, and health facilities, difficulties in accessing affected populations (as in Gaza), climate crises, reduced funding, and its instrumentalisation for military purposes have made the limitations of humanitarian action in ensuring adequate health assistance and effectively protecting affected populations even more evident.

The Commission’s Report

Never before has the gap between assistance needs and available resources been so wide.²⁰ In this context, the Commission of the Johns Hopkins Center for Humanitarian Health and the Lancet on Health, Conflicts, and Forced Displacement (hereafter referred to as the Commission) was established in 2024, with three main objectives: 1. to analyse barriers and enabling factors for humanitarian action in the health sector; 2. to use the priorities of communities affected by conflicts and forced migrations as a reference for change; 3. to formulate realistic recommendations based on available evidence. The Commission brought together 21 commissioners – representatives from the humanitarian and academic worlds – assisted by young collaborators. The work, spanning two years, was based on a review of existing literature, the academic and operational expertise of the commissioners, and interviews with 553 humanitarian workers and individuals affected by crises.

Since different types of crises require differentiated responses, the report, launched in May 2026,²¹ distinguishes between new acute crises, acute-on-protracted crises, and protracted crises. In these contexts, the collapse of basic health care and interruptions to chronic care, along with shortages of water, food, and security, cause more excess deaths than direct violence.

The Commission reconsiders humanitarian principles as operational tools. Humanity and impartiality remain essential; neutrality and independence, instead, should be applied flexibly and pragmatically according to the context, to ensure access to populations affected by crises. The report also proposes to complement traditional principles with “do no harm”²² solidarity, and accountability, understood as responsibility to all stakeholders, for effective and evidence-based interventions.

According to the Commission, the humanitarian system does not need minor, incremental changes, but a profound transformation, with a single United Nations agency tasked with coordinating and managing humanitarian interventions. This change should be based on four principles, which lead to corresponding recommendations directed at states, non-state actors, multilateral institutions, and humanitarian leaders:

• Reverse power dynamics by transferring resources and decision-making capacities to affected communities, which must become protagonists in decisions rather than mere beneficiaries;
• End impunity by strengthening accountability for violations of humanitarian law through more effective monitoring mechanisms;
• Promote more equitable, stable, and predictable funding, oriented toward real needs and not subordinated to the political priorities of donors;
• Ensure universal protection of the right to health, guaranteeing not only access to quality and continuous care but also the protection of health infrastructures and, where possible, the integration between humanitarian and national systems.

A call to act differently: Towards a different humanitarian strategy in a changed context

The nature of humanitarian crises has drastically changed in recent years. Attacks on hospitals and health personnel have become the norm, for example, in Syria, Gaza, and Sudan, in a climate of impunity and political tolerance. Armed conflicts tend to become protracted, sometimes lasting for decades, and to spill over into neighbouring countries. The number of people forced to flee or seek refuge abroad has reached unprecedented levels. Following cuts in humanitarian funding, the number of people to be assisted with humanitarian aid has been brutally reduced, based on a cruel global triage that abandons millions of people in need to their fate.^23,24 It is estimated that these cuts could lead to up to 14 million additional preventable deaths by 2030.²⁵

The long-called-for transformations have not fundamentally altered the structures of the humanitarian system, which, as de Waal observed thirty years ago, has an “extraordinary capacity to absorb criticism without reforming”.²⁶ The humanitarian system remains fragmented, competitive, and inefficient, often unable to respond promptly to the urgent needs of populations affected by crises and increasingly subordinated to the political priorities of donor governments.

The analysis and recommendations of the Commission are not new; however, it is precisely the current context — with the humanitarian system nearing a breaking point — that makes them relevant again and offers humanitarian actors, agencies, and donors a platform and an impetus for change. The Chinese ideogram for «crisis» indeed encapsulates the concept of opportunity as well. There is a strong sense of urgency in the humanitarian world, with organizations engaged in redefining priorities, reducing staff, and adapting their strategies to a context characterized by increasing humanitarian needs and decreasing resources.

However, the transformation called for by the Commission entails difficult choices for humanitarian organizations: shifting the focus of action towards cooperation and solidarity, altering structures and incentives, ceding power and resources to local and national actors, and reducing competition for resources and visibility, even at the cost of sacrificing established institutional interests. It is still too early to assess how the report has been received by donors and humanitarian organizations and whether, and to what extent, its recommendations can be translated into reality. As Halima Begum wrote in a recent article: “The dinosaurs of international aid must adapt or die: their expensive era is over”.²⁷

Conflicts of interest: none declared.

References

1. Colombo S, Checchi F. Decision-making in humanitarian crises: politics, and not only evidence, is the problem. Epidemiol Prev 2018;42(3-4):214-25. doi:10.19191/EP18.3-4.P214.069
2. Spiegel P, Blanchet K, Undie CC; CHH-Lancet Commission on Health, Conflict, and Forced Displacement. Transforming the humanitarian system, not destroying it. Lancet 2025;405(10483):973-74. doi:10.1016/S0140-6736(25)00344-7
3. Colombo S, Pavignani E. Recurrent failings of medical humanitarianism: intractable, ignored, or just exaggerated? Lancet 2017;390(10109):2314-24. doi:10.1016/S0140-6736(17)31277-1
4. Frank S. Reporting disasters: famine, aid, politics and the media. London: Hurst & Co.; 2013.
5. Terry F. Condemned to repeat? The paradox of humanitarian action. Ithaca (NY): Cornell University Press; 2002.
6. Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP). The state of the humanitarian system 2015. London: ALNAP; 2015. Available from: https://alnap.hacdn.io/media/documents/alnap-sohs-2015-web.pdf
7. Overseas Development Institute Relief and Rehabilitation Network. The Joint Evaluation of Emergency Assistance to Rwanda: Study III. Principal findings and recommendations. Network Paper 16. London, ODI; 1996. Available from: https://alnap.org/help-library/resources/network-paper-16-the-joint-evaluation-of-emergency-assistance-to-rwanda/
8. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994? Lancet 1995;345(8946):339-44.
9. International Federation of Red Cross and Red Crescent Societies. The Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief. Geneva: IFRC; 1994.
10. The Sphere handbook: humanitarian charter and minimum standards in humanitarian response. Geneva: Sphere Association; 2018.
11. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Humanitarian response review. New York: OCHA; 2005. Available from: https://interagencystandingcommittee.org/sites/default/files/migrated/2014-12/Humanitarian%20Response%20Review%202005.pdf
12. Telford J, Cosgrave J, Houghton R. Joint evaluation of the international response to the Indian Ocean tsunami: synthesis report. London: Tsunami Evaluation Coalition; 2006. Available from: https://cdn.sida.se/publications/files/sida61330en-joint-evaluation-of-the-international-response-to-the-indian-ocean-tsunami.pdf
13. Inter-Agency Standing Committee. The IASC transformative agenda. Geneva: IASC; 2012. Available from: https://interagencystandingcommittee.org/iasc-transformative-agenda
14. Inter-Agency Standing Committee, World Humanitarian Summit. The Grand Bargain: a shared commitment to better serve people in need. Istanbul: World Humanitarian Summit; 2016. Available from: https://interagencystandingcommittee.org/grand-bargain
15. United Nations. UN80 Initiative. New York: United Nations. Available from: https://www.un.org/un80-initiative/en (last accessed: 13.06.2026).
16. Inter-Agency Standing Committee. Humanitarian reset. Available from: https://www.thenewhumanitarian.org/analysis/2025/06/16/reset-reform-or-repeat-humanitarianisms-reboot-searches-right-script (last accessed: 13.06.2026).
17. Spiegel PB. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. Lancet 2017;S0140-6736(17)31278-3. doi:10.1016/S0140-6736(17)31278-3
18. Spiegel PB, Karadag O, Blanchet K, Undie CC, Mateus A, Horton R. The CHH-Lancet Commission on Health, Conflict, and Forced Displacement: reimagining the humanitarian system. Lancet 2024;403(10433):1215-17. doi:10.1016/S0140-6736(24)00426-4
19. DuBois M. The new humanitarian basics. London: ODI Humanitarian Policy Group; 2018. Available from: https://media.odi.org/documents/12201.pdf
20. Humanitarian Action. Trends in crises and needs: a world at breaking point. 08.12.2005. Available from: https://humanitarianaction.info/document/global-humanitarian-overview-2026/article/trends-crises-and-needs-world-breaking-point (last accessed: 08.05.2026).
21. Spiegel P, Martínez E, Abrahim O, et al. Johns Hopkins Center for Humanitarian Health-Lancet Commission on health, conflict, and forced displacement: health in a world of crises and impunity. Lancet 2026;407(10543):2065-140. doi:10.1016/S0140-6736(26)00564-7
22. Anderson MB. Do no harm. How aid can support peace or war. Boulder: Lynne Rennier; 1999.
23. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global humanitarian overview 2026. New York: OCHA; 2025. Available from: https://www.unocha.org/publications/report/world/global-humanitarian-overview-2026-enesfr
24. Fletcher T. Salvar 87 millones de vidas cuesta menos de lo que el mundo gasta en juguetes para mascotas. El País, 04.06.2026. Available from: https://elpais.com/planeta-futuro/2026-06-04/tom-fletcher-jefe-humanitario-de-la-onu-los-recortes-nos-obligan-a-elegir-que-vidas-salvar-y-que-vidas-no.html
25. Cavalcanti DM, de Oliveira Ferreira de Sales L, da Silva AF, et al. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis. Lancet 2025;406(10500):283-94. doi:10.1016/S0140-6736(25)01186-9
26. de Waal A. Famine crimes: politics and the disaster relief industry in Africa. Bloomington (IN): Indiana University Press; 1997.
27. Begum H. The dinosaurs of international aid must adapt or die – their expensive era is over. The Guardian, 22.05.2026. Available from: https://www.theguardian.com/global-development/2026/may/22/aid-international-charity-frontline-adapt