Gaby Daw, Caritas Jordan

On 30th June, donors, UN agencies and governments hosting refugees from Syria meet at ministerial and senior official level for the Brussels IV Conference titled “Supporting the future of Syria and the region.” The Syrian regional crisis response has been a kind of laboratory for experiments in new approaches to the ‘localisation’. Based on my work with Caritas Jordan, a national NGO delivering assistance for Syrian refugees, alongside poor and vulnerable Jordanians, and migrants and refugees of other nationalities, this blog outlines three priorities for action to strengthen support to the leadership role of national and local actors in humanitarian action.

First of all, a little information about Caritas Jordan and its contribution to a localized response to the Syrian crisis response here. When the Syrian refugees first came across the border, Caritas Jordan was amongst the first organisations to provide assistance. This built on our much longer-term experience in support to refugees, notably including refugees from Iraq. One aspect of this experience was that we have a history of working in partnership with local Muslim faith-based organisations. In doing so, we have both sought to use our relationships with local faith leaders to both fundraise for our humanitarian work, gather donations and mobilise volunteers and staff, and to work with them to spread messages about social cohesion and welcoming people fleeing violence in a non-discriminatory fashion, irrespective of faith, gender or other social characteristics. Indeed, some years later, UNHCR and Western donor nations started to recognize the importance of providing support to the Jordanian ‘host community’. It was actually a national Muslim faith-based organization, which first drew attention to this and indeed also received some criticism for doing so at the time.

More recently, as the global Covid19 pandemic came to Jordan, Caritas Jordan has also worked actively alongside other national organisations to adapt our programmes. In doing so, we have tried to both address new risks and vulnerabilities caused by the spread of the virus, as well as to continue addressing on-going humanitarian needs. For example, Caritas Jordan plays a significant role in provision of primary health services to both Jordanians and refugee and migrant communities in the country. From the outset of Covid19, we worked to ensure sustained delivery of medicines to chronic patients. Drawing on flexible funding from our INGO partners and back-donors, Caritas Jordan already in April agreed and implemented a system for delivery of medicines to patients using the local pharmacies it has had agreements with for years and with the delivery company UPS.  Speed of action on this was possible because of our INGO partners and certain back-donors allowed for flexibility, and because local pharmacies were still open for business despite the lockdown. Following very positive patient feedback from the first UPS deliveries in April funded from our INGO partners, UNHCR decided to use UPS also when it came to delivery of medicines to patients supported under the UNHCR/Caritas Jordan grant in May.[1]

From the perspective of Caritas Jordan, there are three critically important issues that it would be helpful for international donors to consider when they reflect on options to strengthen the localised response to the Syrian crisis in Jordan:

[1] Recognise the contribution of national civil society in the context of Humanitarian/Development ‘Nexus’ approaches to aid funding and systems strengthening – Building on commitments made at the London Conference on Syria in 2016, the Global Compact on Refugees, and wider discussions on Humanitarian/Development ‘Nexus’, there has been a much-appreciated focus on supporting the Government of Jordan to respond to the Syrian refugee crisis, and cope with the social and impacts of this for Jordanians and others in the country. This has included the establishment of a Multi-Donor Account, through which donors and the World Bank can channel funds to support a coordinated approach across different line ministries. This has enabled a more joined-up approach across development and humanitarian funding, and support to both refugees and the local host community.

As a large-scale provider of primary health services to refugee populations in Jordan, Caritas Jordan has made important contributions to these wider efforts over the years in coordination with both the Government of Jordan Ministry of Health, WHO, UNHCR and other agencies involved. This remains an on-going effort to maximise a more coherent approach across the different actors involved to promote a truly comprehensive approach to national health systems strengthening. In Jordan, primary health care services are in practice delivered by MoH operated clinics, private GP practices, national NGO-run clinics, UNWRA clinics and international NGO-run clinics. Secondary Healthcare services are delivered by MoH operated hospitals, military hospitals, royal hospitals, private hospitals and “charity” hospitals. Coordination and alignment across these is important.

Caritas Jordan has worked for years to ensure its primary-health clinics are run in ways that align with and implement Government policy and practices. Indeed, beyond this, we have also worked with the Ministry of Health on its efforts to strengthen national policy and guidance on primary healthcare. This included facilitating a study tour to Denmark during which Jordanian officials and Danish officials exchanged good practices in terms of organisation, structure and funding of healthcare at national, regional and municipal levels, public-private partnerships between the health authorities and private GPs in delivering primary health care services to citizens, as well as the broad and successful collaboration between municipalities and civil society organisations in the promotion of health awareness and healthy living. [2] We are proud of our partnership with the Ministry of Health on these kinds of efforts.

Budgetary constraints, both those faced by the Government of Jordan and by UNHCR, impact on our collective efforts to enable a coherent approach. For example, the UNHCR funds we receive can only be used to support patients with the appropriate UNHCR registration letter, which not all Syrian refugees have, and some refugees with other nationalities do not have access to. UNHCR funds also only permit us to refer patients to public hospitals, which tend to suffer from longer waiting lists, postponement of surgeries and other challenges, in contrast to better-resourced private hospitals. There are no easy solutions to these challenges, which reflect primarily budget constraints. But, alongside others, we have advocated for a ‘one refugee approach’, which would mean that funds can be used in a flexible fashion to support all refugees, regardless of nationality. Nothing illustrates the importance of a joined-up approach more than the Coronavirus. If the response to COVID-19 is going to deliver successful outcomes for all residents of the country, then we need a standardized and inclusive whole of country approach to the identification, testing, diagnosis, referral and treatment with full buy-in from all primary and secondary healthcare service providers.

[2] Provide adequate overheads costs for national NGOs – Most UN organisations do not provide overhead costs, only in-country operational costs. This can include capacity-strengthening of partners but only in so far as this is directly related to and necessary for delivery of the programme/project which they are funding – in other words, not wider overhead or core costs.

For example, UNHCR provides for 4 percent, which can be spent on staff capacity-building and other basic costs for the project delivery. Whilst we very much appreciate the partnership with UNHCR and these funds, Caritas Jordan and other projects supported by other donors effectively subsidise the UNHCR-funded programmes. As the Covid19 crisis has again demonstrated to us all, working on humanitarian response is a hugely complex, challenging and risk exercise. UN agencies, like UNHCR, should agree to an increased contribution to national NGOs’ overheads costs and they should standardise this globally. Donors should require that INGOs and UN agencies, especially those receiving multi-year, flexible funding, provide adequate overheads support to national and local partners.

[3] Provide sustained multi-year funding to national organisations – In the wider discussions on quality funding under the Grand Bargain, donors and UN agencies have recognised the importance of sustained provision of multi-year, unearmarked funding for protracted crisis situations like the Syrian refugee response.

Since 2018, Caritas Jordan has benefited from multi-year funding from the Danish Ministry of Foreign Affairs channelled via an INGO intermediary organisation in the Caritas confederation. Prior to this, only 1-year humanitarian programme responses could be submitted, which presented challenges in terms of planning and implementation in what has now become a 10-year long protracted displacement crisis. The new longer-term funding allows for greater room for testing new programmatic approaches and operating modalities and an acceptance that not all of these will necessarily be fully successful (e.g. piloting repeat prescriptions which at the time was not common practice by any of the health providers in Jordan and is today used by Caritas, MoH and UNHCR). The Strategic Partnership Agreement also allowed for more innovative approaches, such as through greater collaboration between humanitarian and development actors (e.g. the Study Tour and discussions with Jordanian health authorities on a more viable and sustainable future primary healthcare system in the country).

Effective human resources, finance, logistics, procurement and risk management all require longer-term investment. Likewise, effective resilience approaches to protracted crises, such as livelihoods programming, also need longer timeframes to yield results. Yet this kind of funding from the Danish Government is not the norm. Most of the multi-year, flexible funding has gone to UN agencies and just a handful of INGOs, who are not yet held accountable for how they pass its benefits onto national and local partners. The majority of humanitarian funding remains short-term and inflexible.

UNICEF, for example, recently published the results from an study on how it cascades multi-year funding to its implementing partners in Jordan and Lebanon, including national NGOs. That study highlights the ways in which restrictive conditions (including detailed logical frameworks, as well as high requirements for risk management and due diligence) and earmarking by most donors have constrained the benefits of multi-year funding to support work on the ground.

As the economic impacts of Covid19 are felt globally, it is likely that aid budgets will shrink, and decisions will be made about how this impacts on multi-year, flexible funding. We hope that funding for our vital, frontline provision of primary healthcare is safeguarded in this context.

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Footnotes:

[1] Other aspects of our adaptation to Covid19 included making arrangements for those patients that needed emergency surgeries to access hospitals. Various other steps were taken to distribute personal protective equipment, train staff and factor in social distancing, hygiene, sanitation and other guidance on adapting to Covid19 into our programming. For example, we scaled up the use of phone and Whatsapp to schedule appointments at our health centres; and took specific additional steps to enable the elderly and other vulnerable patients to access primary healthcare safely.

[2] The organization of the study tour to Denmark was only made possible through the longer-term funding provided to Caritas Jordan. Feedback from delegates was that the Study Tour was very relevant and inspiring as Jordan embarks on shifting a larger percentage of healthcare provision from secondary to primary healthcare levels in line with WHO guidelines. In that respect, the delegation believed Denmark provides some interesting models for replication.