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Humanitarian health exists at the intersection of two competing demands. On one side lies the urgent need to deliver medical care and prevent disease outbreaks in the immediate aftermath of war, natural disaster, or displacement. On the other side lies the recognition that crisis-affected populations need more than emergency relief: they need health systems that can survive the next shock, and they need those systems to be owned and shaped by their own communities. This tension—between rapid, standardized relief and long-term, locally rooted capacity—has driven the evolution of humanitarian health as a field of inquiry and practice. The frameworks that follow represent successive attempts to define what humanitarian health should prioritize, who should lead it, and how its success should be measured.
In the 1970s, the dominant framework for health in crises was disaster medicine. Its central question was clinical: how can medical teams treat the injured and sick when normal health infrastructure has collapsed? Disaster medicine focused on triage protocols, field surgery, epidemic control, and the logistics of getting supplies and personnel into affected areas quickly. Its practitioners were largely emergency physicians and military medical officers, and its unit of analysis was the individual patient or the single disease outbreak. The framework assumed that crises were exceptional, time-limited events, and that the appropriate response was a temporary surge of external expertise. What disaster medicine did not address was the fact that many of the world's worst health emergencies—civil wars, protracted displacement, recurrent famine—were neither short nor exceptional. They were chronic conditions produced by political instability, poverty, and weak governance.
By the 1990s, the limitations of disaster medicine had become impossible to ignore. The wars in Somalia, Bosnia, Rwanda, and the Democratic Republic of Congo created health crises that lasted years, affected entire regions, and killed more people through the collapse of public health systems than through direct violence. The framework of complex humanitarian emergencies emerged to describe this new reality. It shifted the unit of analysis from the individual patient to the population, and from the acute event to the protracted crisis. Complex humanitarian emergencies drew attention to the social determinants of health in conflict settings: food insecurity, displacement, sexual violence, the destruction of water and sanitation systems, and the breakdown of routine immunization and maternal care. Where disaster medicine had asked "how do we treat the wounded?", the complex humanitarian emergencies framework asked "how do we keep an entire population alive when its health system has disintegrated?" This shift opened the door to a broader set of interventions—nutrition programs, disease surveillance, reproductive health services, mental health support—that went far beyond emergency surgery. But it also raised a new question: who should coordinate these diverse activities, and under what standards?
In the late 1990s and early 2000s, the field began to formalize its operational approach under the label humanitarian health response. This framework took the population-level perspective of complex humanitarian emergencies and turned it into a standardized package of interventions. Humanitarian health response is best understood as the effort to deliver essential health services—primary care, maternal and child health, vaccination, disease surveillance, nutrition—through parallel systems that operate alongside or in place of the local health infrastructure. Its hallmark is the use of standardized protocols, such as the Sphere Handbook's Minimum Standards in Health, and the deployment of international nongovernmental organizations (NGOs) as the primary service providers. The framework's strength is speed and accountability: when a crisis hits, a well-funded NGO can set up clinics, train local staff on a standard curriculum, and report measurable outputs (patients seen, vaccines given) to donors within weeks. Its weakness is that it often creates a parallel health system that disappears when funding dries up, leaving local institutions no stronger than before. Humanitarian health response thus embodies the vertical, relief-oriented pole of the field's central tension.
Directly challenging the logic of parallel relief, the framework of health systems strengthening in fragile states emerged around the turn of the millennium. Its core argument is that humanitarian health interventions should not merely deliver services but should actively rebuild and reinforce the local health system—its workforce, financing, governance, supply chains, and information systems. This framework draws on the broader global health movement toward health systems strengthening and universal health coverage, but adapts it to the specific conditions of conflict-affected and politically unstable settings. Where humanitarian health response treats the crisis as a temporary interruption that requires an external fix, health systems strengthening in fragile states treats the crisis as a symptom of underlying institutional weakness that must be addressed through long-term investment. The two frameworks coexist in a state of productive tension. In practice, most humanitarian operations combine elements of both: an NGO may run emergency clinics while simultaneously training Ministry of Health staff and helping to restore the cold chain for vaccines. But the frameworks disagree on where the center of gravity should lie. Humanitarian health response prioritizes immediate access to care; health systems strengthening prioritizes the durability of the system itself.
As the number of actors in humanitarian health multiplied—UN agencies, international NGOs, bilateral donors, private foundations, local civil society—the need for coordination and accountability became acute. The framework of humanitarian health governance emerged to address this institutional complexity. It focuses on the rules, norms, and organizations that shape how humanitarian health is funded, led, and evaluated. Key elements include the cluster system (in which the World Health Organization leads the health cluster in a crisis), the Humanitarian Programme Cycle, the Grand Bargain on donor effectiveness, and the various codes of conduct and accountability standards that NGOs have adopted. Humanitarian health governance does not prescribe which clinical interventions to use or how to strengthen a health system; instead, it asks who makes decisions, how resources are allocated, and whether the system as a whole is accountable to affected populations. In this sense, it provides the institutional architecture within which the debate between relief and systems takes place. But governance frameworks themselves are not neutral: they reflect the power of the wealthiest donors and the largest international organizations, and they have been criticized for being top-down and donor-driven.
The most recent framework, decolonizing humanitarian health, emerged in the mid-2010s as a direct challenge to the assumptions underlying all previous frameworks. Its central claim is that humanitarian health, as currently structured, reproduces colonial patterns of power: decisions are made in Geneva, London, and Washington; funding flows through Northern institutions; and local health workers and communities are treated as implementers rather than leaders. Decolonizing humanitarian health does not merely call for more local participation within existing structures; it calls for a fundamental redistribution of authority over humanitarian health policy, funding, and knowledge production. This framework critiques humanitarian health governance for being an architecture of control rather than accountability, and it argues that health systems strengthening in fragile states cannot succeed if it is designed and imposed by external actors. Decolonizing humanitarian health shares with health systems strengthening a commitment to local capacity, but it goes further by insisting that capacity building must be accompanied by the transfer of decision-making power and financial control. It also challenges humanitarian health response's assumption that international standards and protocols are universally applicable, arguing that they often erase local knowledge and priorities.
Today, the three most active frameworks—humanitarian health response, health systems strengthening in fragile states, and decolonizing humanitarian health—coexist in a state of live disagreement. They agree on several points: that crisis-affected populations need access to quality health services; that coordination among actors is essential; and that the ultimate goal should be to reduce suffering and save lives. But they disagree sharply on the pace and direction of change. Humanitarian health response argues that in an acute crisis, speed and standardization are paramount, and that system building can wait until stability returns. Health systems strengthening in fragile states counters that waiting is a luxury the field cannot afford, because every parallel clinic built today is a missed opportunity to strengthen the local system for tomorrow. Decolonizing humanitarian health argues that both frameworks miss the deeper issue: as long as power and resources remain concentrated in the global North, even the best-intentioned interventions will perpetuate dependency. The field's future will be shaped by how these three frameworks negotiate their differences—whether they remain in tension, find points of synthesis, or give way to new approaches that none of them have fully anticipated.