When international mandates obstruct health systems resilience in conflict: Insight from a causal loop analysis of a humanitarian program

Background: The Lancet Commission on health, conflict, and forced displacement recently offered a precise diagnostic overview on the dysfunctions of the international humanitarian system. Through an extensive research and analysis involving global health data and local perspectives, it has called for shifting governance in general, and decision-making in particular, towards local actors and communities, promoting true accountability in practice rather than exclusively in policies (1). A case study conducted on a humanitarian health programme in Lebanon has highlighted how decision-making processes in international actors can often be inward-looking and mandate-driven, rather than centred on people’s needs (2). Methods: Drawing on a single in-depth case study through a complex adaptive systems lens, and centring decision-making as key governance dimension of focus (3,4), we developed causal loop diagrams (CLDs) through group model building, based on the secondary data analysis, and revised through a participatory session with humanitarian workers and bilateral conversation with experts in health systems resilience. Results: The CLDs illustrate the causal relationships influencing decision-making behaviours within humanitarian organizations. Within the CLDs, we identified balancing and reinforcing loops governing the absorptive, adaptive, and transformative capacities of humanitarian health programmes, showing the relational, institutional, and political drivers of resilience. Accountability to affected populations, staff well-being, and public health evidence remain at the periphery of decision-making processes, and do not participate in shaping resilience capacities. Organizations are seen as accountable to the affected populations they select, with the selection following the organizations’ mandates rather than population needs. Such statements clarify the mechanisms behind and outside the loops: mandate boundaries are set before any operation begins, and decide who counts as affected population, so that accountability follows the mandate rather than driving it. Discussion and conclusions: The findings of this study clarify the causal architecture behind the missed opportunity to contribute to health systems resilience strengthening in conflict that the Lancet Commission calls for, suggesting the power bottlenecks that can make accountability, staff well-being, and public health evidence aspirations not functionally integrated into the formal decision-making loops that drive humanitarian organisations’ behaviour. While this study identifies the mechanisms that make humanitarian actors fail the people they are meant to serve, it does not yet identify a way to change this. It does however suggest a starting point: mandates, even when entrusted by states, exist to serve populations, not to sustain the organisations that hold them. Reaffirming this principle in practice, and not only in policy, may be the precondition for international humanitarian actors to stop functioning as gatekeepers of the needs they were set up to meet.