The delivery of humanitarian aid, the way in which the aid system is structured and the needs that it aims to address, are all influenced by a constantly evolving political landscape. Our patients are criminalised and excluded from accessing care. Our solidarity with the most vulnerable is contested. MSF – like many other medical actors and humanitarian organisations – faces extreme challenges in delivering aid where state sovereignty is asserted in a context of changing global power dynamics. In many places, patients and their care providers are under attack, be it on the frontlines of conflicts, in the response to migrants or in the struggle to provide treatment to people living with HIV. This requires MSF to forge new alliances as we seek to overcome the challenges facing patients to access healthcare.

The MSF Operational Center in Brussels launched a process of consultation among staff and association members throughout the organisation in order to feed in to the next four year strategic plan from 2020 to 2023. A number of working groups were created to analyse our political and aid environment and the medical humanitarian needs we encounter. Other working groups were set up to explore the way in which we respond to needs through our patient centred medical humanitarianism.

This document – which we have decided to make publicly available – contains the outcomes of the first three working group reflections on the political environment, aid environment and medical humanitarian needs. It is a working document that contains an evolving analysis based on broad consultation. We welcome feedback and points of reflection or disagreements that will help us to continue refining our understanding of the environment in which contemporary medical humanitarian aid is delivered and what it means for the strategies we adopt to reach the most vulnerable.

Political Environment

MSF is not an apolitical organisation. While it is clear that MSF is not driven by political interests, our medical humanitarianism is deeply political. This is because we impartially provide treatment, alleviate suffering and restore dignity to those whose basic existence is under threat by the prevailing political order. It is for this reason that we must analyse our political landscape, not to be driven by it, but rather to understand how our medical act interacts with it and how we can better navigate it for the sake of our patients.

One of the primary features of our contemporary external environment is the assertion of national self-interest. This is not a new. States, by their very definition, preserve their self-interests. What is new is the exact power configurations in which that is currently taking place.

The post-Cold War era of political dominance by the Western liberal order is in decline. We are faced today with a changing political landscape. Whereas in the past we may have been operating on a two dimensional chessboard of the ‘west versus the rest’, with humanitarianism largely associated with western political interests that had the leverage to assert its influence, today we are faced with a three dimensional chessboard. This is characterised by a diffusion of political power from a unipolar order to a multipolar landscape that is seeing (re)emerging states or regional blocs asserting greater influence; social movements that challenge states and mobilise through new technology; and a traditional power structure maintaining military might while retreating into self-interested protectionism.

Across the spectrum of emerging powers and declining traditional state super-powers we see a rise in right wing fascism and nationalism that demonises migrants, stigmatises minorities, privatises social services and criminalises those who try to treat the undesirables, often with popular support mobilised online. Humanitarian actors, still largely associated with a western project of liberal multilateralism that has lost credibility, encounter resistance from states on the receiving end of humanitarian assistance. These states are now able to find new allies among emerging or re-emerging powers. This can often be at a regional level where emerging powers have more space to project a regional political agenda or at a global level where certain (re)emerging powers express a bigger ambition. The political fault lines that we witness are often resembling those of the Cold War.

At the same time, humanitarian actors are being controlled and used to advance an increasingly more conservative political agenda from their traditional donors; an agenda that is largely characterised by keeping out migrants, fighting terrorism and promoting economic interests. This is reflected for example by the now standard donor anti-terrorism clauses that criminalise an often vague or expansive definition of ‘support to terrorism’ or by the way in which ECHO has organised itself to implement Europe’s anti-immigrant political agenda.

For people caught in conflicts, this broader political landscape is creating space for wars to be fought without limits. A counter-terrorism logic is expanding across conflicts as the ‘war on terror’ is adopted as the justification of choice for local counter insurgencies that are often fought with the support of international military coalitions. The ‘with us or against us’ approach to counter-terrorism warfare fought under domestic laws seeks to stretch the limits of IHL by eroding or excluding the protected status of the civilian, including the rights of wounded combatants.

While the West may be perceived to be in less of an interventionist mood with a focus on domestic interests, this does not exclude the ongoing military, economic and political interference in contexts that are seen as a direct challenge to US self-interests. This is most clearly seen in the expansive use of sanctions regimes (against Venezuela, Iran, North Korea, Syria and others), the ongoing use of targeted drone strikes, with what appears to be looser rules of engagement (in Somalia, Pakistan and Yemen), and the trade wars with the emerging super power of China. While North America and Europe retreat from asserting hard and soft power, China is taking up increasing space with vast economic investments across the African continent, Central Asia and Southern Asia as well as through the training of medical workers from allied countries inside China.

For people on the move, the deterrence of migrants and the externalisation of borders are the new normal, from fortress Europe to Australia and Latin America. Migrants are being characterised as a security threat. National politics often centre around who has the most extreme view on migrants, with a rise  of the right wing claiming increasing legitimacy in their racist demonization of ‘the other’.

For women, attacks on reproductive rights is seeing a resurgence in the restrictions on safe abortions and other sexual and reproductive health services. For minorities and specifically vulnerable groups, stigmatisation and criminalisation are being normalised often with the backing of organised religion.

In addition to the usual difficulties of working in countries exerting extreme controls on their population and on aid, the general environment is setting limits on what is considered to be acceptable forms of humanitarian aid. Those who step beyond these limits by treating ‘terrorists’, assisting migrants or treating the ‘undesirables’ risk being criminalised at best or come under direct attack at worst.

These political changes are occurring in a period of rapid urbanisation and growing inequalities – with chronic urban violence – where the effects of climate change, and the political reality of its denial, are becoming more apparent.

Social movements are reacting to these broader political realities by mobilising around the social fault lines that are accentuated by economic injustice. For example, students in South Africa are calling for an end to university fees and a decolonisation of the curriculum in response to inequalities in post Apartheid SA; students across the world have denounced the political failures to tackle the reality of climate change; in Brazil, people took to the streets to honour the legacy of Marielle Franco, a black, gay, feminist city councillor from the favelas who was assassinated in Rio. What unites many of these movements is a struggle rooted in the reality that racism, sexism, homophobia and transphobia, patriarchy and ableism are all part of the power structures of inequality. At the same time, social movements on the right are rallying around nationalism, family values and threats to ‘civilisation’ to advance what many on the left would consider to be an alarmingly fascist expression of unjust power structures. These social movements on the right have been successful in many parts of the world in putting their representatives in office from Duterte in the Philippines to Trump in the US, Bolsonaro in Brazil, Modi in India and Erdogan in Turkey. The list is long and constantly getting longer.

What does this overall political landscape mean for MSF and our patients? In short: humanitarianism is under attack. While the need for our independent and direct model of operational delivery remains in demand, we are increasingly targeted in the countries we work and in our home societies. Our traditional allies in the general public are increasingly polarised.

Across our areas of operations there will likely be a growing suspicion toward foreign humanitarian aid. Our legitimacy will not be weighed by our medical relevance alone but in some contexts could also be based on our rootedness in civil societies and social movements, our public voice as an international movement and our ability to engage with fragmented armed groups and strong assertions of nationalism.

The changing military, economic and political power structures we encounter have a direct impact on all of the different elements of MSF’s work. It changes the equation of who can unlock access to the most vulnerable, it alters the considerations on who has power to change a situation that we want to advocate on, and it influences the financing that is channelled from the public to us and to actors that we rely upon to work alongside us in some of the most difficult environments–be it in the frontlines of the war in Yemen or in the battle against HIV.

Within this political environment a defence of impartial humanitarianism is essential. The direct act of saving lives in accordance with medical ethics is a radical position in a political environment of exclusion, nationalism and criminalisation.

Aid environment

The traditional humanitarian aid system, of which MSF is a prominent member, was shaped by its major western state donors and the rise of the liberal political order. National self-interest was never far from the surface, using international aid to promote specific models of governance, solidify strategic alliances, and foster greater economic ties. Aid recipient countries largely depended on European and North American financial, political and military power and had little choice but to accept the aid and its agencies that came with it. Now that global power is more diffused, states can shop around for international political and financial support from countries with a different set of strings attached.

Western aid donors have narrowed the scope of their aid objectives away from grandiose poverty reduction projects to a more narrow definition of national self-interest to contain threats: terrorism, migration and disease, as well as using aid as a public investment that can benefit businesses at home. Multi-mandate aid agencies worried about losing funding are largely compliant with this agenda, and recipient states re-assert their sovereignty in order to control the international aid flows.

The aid system and its donors responded to these dynamics by reshaping aid architecture accordingly. The long-held desire to merge state-building and development with humanitarian aid through concepts like ‘resilience’ culminated in the World Humanitarian Summit in Istanbul in 2016.  This resulted in the so-called humanitarian-development nexus whereby development, humanitarian aid and peacekeeping should all work together in conflict induced emergencies to support the host government respond to crises within their sovereign territories.

The United Nations pledged to implement this in their so-called New Way of Working (NWOW) which puts host governments firmly in the driving seat of the aid machine, and encourages local and national actors to respond. The nexus and NWOW aim to ‘end need’ by tackling root causes of underdevelopment and assist governments in their state-building efforts. The major aid donors supported these changes through the ‘Grand Bargain’ in which they pledged that at least 25 percent of their aid budget will be channelled to national and local responders by 2020.

While the merging of humanitarian and development aid is not new, it is now much more overt and widely accepted. Putting the host government in overall charge of aid in conflict situations creates a strain on impartiality, as the state is one of the belligerents in ongoing violence. Dangerous narratives are reinforced, where governments believe INGOs work for them and armed groups think INGOs work for the state and not the population in need. Impartiality comes under threat if governments control which people aid agencies are allowed to reach. Moreover, the reality is ignored that humanitarian needs are not exclusively due to under-development, and thus states are released of their responsibility in causing any humanitarian needs to start with.

While the effectiveness of the traditional aid system is increasingly under question (including by MSF), new or newly-noticed aid actors are populating the aid arena, including from the private sector and private foundations. The localisation agenda promotes an increasing role for national responders, in part to cut costs but also to revive the capacity-building or partnership models of the past. Many of the newly noticed aid actors originate from non-western donor nations who channel funds into their own organisations to further their foreign policy and trade objectives (as do western donors). Some define certain aid programmes in more overtly partisan terms (Qatar, Turkey, Russia).

Citizens-led aid response is on the rise, as seen in the recent migration reception crisis in Europe. Citizens filled the gap left by European States’ deterrence policies by seeking to enforce human rights. The conflict in Syria is another example where the vacuum left by the traditional aid system unable (access denied by Syrian State) or unwilling (too dangerous after numerous kidnappings) to respond was filled by Syrian citizens locally and abroad. They self-organised, creating aid organisations on the ground and abroad from the diaspora who took on the bulk of the aid response in hard to reach areas. However, in other domains such as HIV, local activist movements (especially in Southern Africa) are under increasing pressure as they struggle to find resources while donors withdraw.

In another effort to increase efficiency of aid, the private sector and private foundations are viewed as natural aid partners and possible solution creators. The World Bank has become increasingly active in the humanitarian and health arena, particularly in fragile and conflict-affected states, operating its usual model of a top-down, systems-building approach, with funds funnelled directly through the state. The pendulum of aid funding from donor states to beneficiaries via the UN and NGOs in the 90s and noughties has now swung back to budget support direct to governments. Therefore host government sovereignty is heightened not only by the state-building aid system evolution, but also reinforced by the injection of large-scale World Bank funds.

In the global health arena, with an expanded development agenda via the Sustainable Development Goals, the competition for resources has hardened.  Meanwhile traditional aid (Official Development Assistance, ODA) for health is levelling off despite global commitments to achieve “Universal Health Coverage” (UHC) by 2030. Global health actors such as GAVI, Global Fund and WHO are struggling to reposition themselves under the banner of UHC while competing for declining donor funding in a health financing arena increasingly occupied by multilateral development banks and the private sector. ODA is increasingly labelled “old fashioned” and recipient countries are expected to take responsibility for the health of their people with their own domestic resources. This is especially acute in countries that, according the macro-economic indicators, ‘graduate’ from ‘low’ to ‘middle’ income countries. They are then required to take out loans and invite the private (and for-profit) sector into the health arena. For example, countries tend to revert to Public Private Partnerships (PPP), subcontract for-profit service providers and health insurance schemes that do not necessarily provide accessible and affordable care for the most vulnerable, nor even the majority of the population in these societies.

At the same time, the underlying principles and international legal mandate for humanitarian assistance (IHL) is under threat through expanding counter-terrorism logic. The concept that ‘you are with us or against us’ has expanded to the humanitarian landscape where both national laws and international restrictions either explicitly block assistance to populations considered supporters of terrorism (Nigeria, Syria) or implicitly discourage it through fears of institutional or individual prosecution under anti-terror laws (Afghanistan, Pakistan, Mali, Somalia).

This is especially acute for medical aid providers such as MSF, as medical aid is the only humanitarian service that applies to civilians and combatants alike. The right and the duty of medics to treat everyone is openly questioned and often cited behind closed doors as the reason why health facilities are attacked (‘because you were treating terrorists’). This trend undermines the legal framework (IHL) under which MSF operates in conflict zones, but this criminalisation of aid does not stop there. Refugee law, and its provisions providing rights to those seeking asylum including the right to receive assistance is also challenged, where not only the recipient (‘illegal migrant’) but also those providing assistance (Italy, Hungary) are prosecuted.

Another sea change in our external environment is the launch in 2016 of the WHO Health Emergencies Programme (WHE). This represented a profound change for WHO, adding operational capability to its traditional technical and normative roles. Because the WHO is designed to work for Ministries of Health and not necessarily the population in need, this may create complications in contexts of ongoing political crisis or internal conflict, or for simply marginalised populations. The WHE is meant to build the capacity of Member States to manage their own health emergency risks. Only when national capacities are overwhelmed (and only then) the WHE will assist the MoH to coordinate the international health response for all hazards, including natural disasters, disease outbreaks and conflict.

The WHO is assisting Ministries of Health across the world in setting up Emergency Operations Centres to integrate health services into an emergency management model. This model sets up government-integrated aid responses for health, and will clearly come into MSF’s working sphere. The sovereign state will be more and more firmly in the driving seat – meaning the rest, particularly INGOs, will be increasingly seen as ‘implementing partners’ of their strategy. How to negotiate access with these bodies, and work alongside them without being fully embedded and losing independent assessments and access will present a growing challenge for our teams.

The global environment of increasingly inward-looking nationalistic governments, where aid is positioned to be under the thumb of the host government backed up by direct funding streams for humanitarian aid, will continue to have consequences for MSF operations. These include: direct impact on access to people in need and quality of care provided; increased tensions with national authorities and armed opposition groups; more compromises on basic humanitarian principles and impartiality/medical ethics to ensure or preserve access; and possible greater silence in the face of abuses to avoid jeopardising access.

This evolving aid landscape requires MSF to invest in forming pragmatic new alliances with civil society, communities and social movements as well as different aid actors. It means our teams will need to engage with a more diverse range of actors than the ‘usual suspects’. Our efforts to influence the global health financing system (largely built on international institutions) in order to get attention for vulnerable populations and specific diseases, needs to adapt to a changing power dynamic.

It also requires MSF to distinguish itself from the traditional aid system through its operations and public voice. This will involve MSF developing strong public positions on topics such as counter-terrorism, the global health security agenda and other trends that shape the aid environment.

Medical Humanitarian Needs

The medical humanitarian needs that we encounter are intricately linked to our political and aid environment. Our political environment generates exclusion and vulnerability and the aid environment shapes the way in which needs are prioritised and addressed or not.

This political and aid environment, is characterised by a retreat of the traditional aid system, political exclusion of vulnerable groups from access to basic quality services and the reduction in protection mechanisms in situations of conflict and displacement. At the same time, commitments in global health are in decline threatening the heath advances made in the past decade.

Medical humanitarian needs remain immense. From the classic gaps in access to health care from primary to secondary levels of care, to heavy burdens of infectious diseases among the marginalised and poorest, to growing challenges posed by chronic diseases and antibiotic resistance. MSF-OCB will play a critical role in addressing a diversity of medical needs and speaking out, focusing on a wide range of vulnerable populations and in multiple different contexts that exacerbate these vulnerabilities.

• Global trends in epidemiology and potential changes in health needs and vulnerability

The concept of a global ‘epidemiological transition’ claims that we are witnessing a change in an overall pattern of mortality. This transition is supposedly occurring from one of high mortality among infants and children alongside episodic famine and epidemics affecting all age groups, to one of degenerative and man-made diseases. However, this picture is a simplistic one. While non-communicable diseases are emerging everywhere, acute and chronic infectious disease remain the primary burden of disease and cause of early mortality in the majority of settings where MSF works, such as in sub Saharan Africa.

Even in so called ‘Middle Income’ settings where the non-communicable disease burden (including cancer) is the highest, health problems like measles, cholera, malnutrition, TB and HIV continue to exist but are often limited to specific vulnerable sub-populations, or are concentrated in specific geographic areas that often lack surveillance, identification capacity and comprehensive care.

Factors such as population growth, rapid urbanization and climate change all contribute to a situation where both acute and chronic medical needs are simultaneously concentrated among the most vulnerable. It is often these subgroups that are the target of political disenfranchisement and neglect, which fuels their vulnerability.

Based on our experience, the global health agenda tends to neglect such diversity in our epidemiological landscape. The focus on global figures like GDP and national epidemiological records are biased towards well reported areas and those health problems with a global dimension (such as NCDs, pandemics, etc).

The rapid rise of antimicrobial resistance (AMR), which is most visible in countries with a microbiological lab capacity, remains largely invisible in most countries where MSF works. MSF has been witnessing the increase of resistant pathogens from drug resistant tuberculosis to nosocomial infections where available antimicrobials are not effective anymore. This is occurring in an overall health landscape where treatment guidelines and practices regarding infectious diseases are ill-adapted, where privatisation of health services is promoted, the pharmaceutical market is poorly  regulated,  access to quality-assured medicines is challenged, patient-literacy (and empowerment) is neglected  and where microbiology diagnostic capacity is largely insufficient.

Additional health care gaps or unexpected health needs might appear; in particular when measures that prevent or mitigate communicable, waterborne or vector borne diseases are reduced or interrupted.

• Context

A diverse range of situations can create or increase the degree of vulnerability of specific populations.

Across different contexts – from natural disasters, to conflicts and outbreaks – acute disruptions of existing health services as well as access to shelter, water and food, will continue to generate the emergence of major health and humanitarian crises, even in countries with advanced health systems. These needs will include the need for continuity of chronic care and prevention services.

In conflict contexts, health care provision at all levels is disrupted or destroyed, routine vaccination is interrupted, and there are often increases in blockages in access to the health care services that do exist. Civilians are often targeted or disregarded, generating specific needs in trauma care. Overall vulnerability and exclusion are massively exacerbated in such contexts. MSF’s experience in conflicts such as in the DRC has shown that direct mortality due to violence or outbreaks is superseded by mortality by indirect causes, such as a general lack of access to medical care or food.

This was also noted in the context of an outbreak such as in the West African Ebola crisis, where estimates of indirect mortality due to lack of access to healthcare exceeded Ebola deaths

On top of this, mortality and morbidity in the so-called post-conflict period remains high, more so for people in precarious conditions and specific vulnerable groups.

Growing urbanisation comes with specific vulnerabilities that results in increased numbers of people being more disease prone.

Internal displacement, accelerated by economic inequality, climate change and local insecurity contribute to the emergence of massive peri-urban congestions in mega-cities like Lagos or Kinshasa. Such cities cannot be seen as one entity anymore. In all rapidly urbanising cities with poor populations at the periphery or in urban slums, there is an increase in violence, malnutrition pockets, and intense disease transmission. This occurs alongside the exclusion of sub-groups from basic and secondary quality health services.

The exponential population growth that is predicted will have particular consequences in Africa. This population pressure is likely to fuel violence and displacement.

• Populations

Regarding international migration, a combination of similar factors (population growth, climate change, unstable and precarious living conditions) will likely increase migratory pressure in transit and destination countries. This will occur in a climate of anti-migrant political discourses that fuel violence, while prioritising detention of migrants and their exclusion from access to health care. Europe and Australia have led the way by diverting migratory flows towards alternative countries like Libya or Indonesia. Potential major host countries have initiated similar anti-migration policies in order to reduce any potential ‘pull factor’. Border camps and deteriorating detention conditions contribute to suffering while access to legal services and emergency health care are restricted. This occurs together with violence and abuse on the migration route from transit countries that are unwilling to provide assistance or even basic protection. This is generating major physical and mental health problems.

Other excluded populations will remain particularly vulnerable in the coming period. In the current political environment, groups such as men who have sex with men (MSM), sex workers and IV drug users will face increasing criminalisation, pushing them underground and often out of reach from health and protection services.

Victims of violence, including SGBV and survivors of torture, face challenging legal environments and limited access to care and rehabilitation services, including in the field of mental health.

Women are also considered a vulnerable group, since reproductive health services, including access to family planning and TOP services, are under ongoing attack. Even access to quality and safe antenatal care and delivery, remain a challenge in many of the contexts where MSF works, including among migrant and internally displaced women.

Children continue to face specific vulnerabilities in the majority of contexts where MSF works and services are often ill adapted to this reality.

• Evolution of international Aid funding mechanisms and its impact on medical humanitarian needs  

The general trend towards the reduction of international aid in the health sector, together with an increasingly nationalistic and privatisation agenda, has rapidly undermined the political commitments of the millennium development goals to eradicate major diseases such as TB, HIV and malaria based on a principle of international solidarity. Such ambitions did not survive in the richest countries’ political agendas. Political commitments that were entrenched in the MDG with quantitative targets and funding responsibilities have recently been diluted into meaningless and vague SDG’s, allowing for political disengagement. This was demonstrated in the most recent UN sponsored TB millennium goal conference, which was a toothless replica of the HIV one 18 years ago.

International funding restriction based on the ‘sustainability‘ and resilience argument as opposed to the ‘exceptionalism’ one creates more restrictive eligibility criteria as seen in the end of GAVI’s support for immunisation services and preferential pricing policies. This induced an EPI vaccine purchase interruption in 2018 in Congo Brazzaville where domestic resources were expected to compensate for the withdrawal of GAVI support. Similar examples can be seen in the ending of support to the Worldwide Polio programme.

Global health Initiatives such as the Global Fund and PEPFAR increasingly focus on ‘key’ countries, which are inevitably those countries with a high prevalence, therefore penalising those contributing less to worldwide figures. The World Bank and others that privilege funding of states and systems, are prone to wilfully neglect certain population groups, such as ethnic minorities, non-residents, marginalised people, and those population groups likely to join any political opposition.

In the future, patient fees and out-of-pocket expenses for households in the public system will probably increase. At the same time, the acceleration of a de-facto privatisation of basic health services – both curative and preventive – is leading to decreased coverage and access.

In this context, MSF could be increasingly called on to compensate for emerging shortcomings in pre-existing health services with a potential increased role in gap filling, and a demand for reinvestment in areas handed over to the MOH or other actors.

In conflict environments, the aid system is increasingly aligned to the state – reducing its ability to access populations in areas under control by armed opposition groups. This reality of the aid system set up in conflict often undermines medical ethics and exacerbates needs.

The realities of our political and aid environment, and the changing landscape of medical humanitarian needs, requires a constant evolution of our ways of working. We need to better equip ourselves to identify medical needs in contexts of exclusion, understand vulnerability and design relevant medical humanitarian responses that directly treat patients while exposing the structures of exclusion that deny them access to healthcare. We need to better navigate on the one hand, the need for maintaining our independence, while on the other hand identifying allies among communities, civil society groups and social movements in order to reach the most vulnerable.  This requires flexible operational models that are connected to communities and delivered in proximity to those who need it most. It is in this way that we will ensure our medical humanitarian impact in a hostile political environment.

For correspondence on this document please contact: jonathan.whittall@brussels.msf.org

Members of the working groups:

Kerstin Akerfeldt (Analysis Department) 

Marc Biot (Operations Department)

Vinyak Bhardwaj (South Africa Operations)

Tom Ellman (Southern Africa Medical Unit)

Eric Goemaere (Southern Africa Medical Unit)

Wairimu Gitau (Communications Department)

Michiel Hofman (Analysis Department)

Andy Mews (Nigeria Operations)

Heather Pagano (Analysis Department)

Bertrand Perrochet (Operations Department)

Mit Philips (Analysis Department)

Christina Psarra (Luxor, Medical Department)

Vitoria Ramos (MSF-Brazil)

Asil Sidahmed (Analysis Department)

Marina Siqueira (MSF-Brazil)

Sebastian Spencer (Medical Department)

Christopher Stokes (Analysis Department)

Fasil Tezera (Analysis Department)

Angela Uyen (Analysis Department)

Wilma van den Boogaard (Lebanon Operations)

Jonathan Whittall (Analysis Department)

Alberto Zerboni (Operations Department)

Photo by Rawan Shaif © MSF, 2015.