A dire warning from researchers at The Lancet medical journal says humanitarian aid, particularly in support of global public health systems, has been so reduced that it has become “rationing by design” and now demands an immediate overhaul.
The architecture of the humanitarian system has become so selective and difficult to access that it is merely “survival triage”, more than three dozen researchers from the Johns Hopkins Center for Humanitarian Health and The Lancet Commission on health, conflict, and forced displacement argued in a report published on Wednesday.
The politicisation of aid – when it is linked to national security and foreign policy priorities – is a key factor in the breakdown of the system, particularly after US President Donald Trump returned to power in January 2025 and gutted the US Agency for International Development (USAID).
For decades, Washington had been the world’s largest donor to humanitarian projects around the globe.
What began as a 90-day freeze on foreign assistance turned into an almost complete dismantling of American humanitarian efforts. By July 2025, USAID was fully shut down and its functions transferred to the State Department.
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“The biggest concern that I think many of us had with the [US] administration was not their diagnosis, but their method, or how they did it,” Paul B Spiegel, the director of the Johns Hopkins Center for Humanitarian Health and chair of the commission that authored the report, told Middle East Eye about the initial intent to slash wasteful spending in the aid space.
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“Number two is the anti-refugee, populist sentiment is not helpful. And then number three is concerns about international humanitarian law,” he added. “Humanitarian law has been broken, not just by this administration, but across the board by everyone, and I don’t see in this administration a push towards accountability.”
Last month, the Organisation for Economic Co-operation and Development said humanitarian aid provided by the world’s richest nations dropped by nearly 25 percent in 2025 compared to 2024, and much of that was because the US slashed more than half of its foreign aid projects.
The Lancet report, citing the Global Humanitarian Overview from the United Nations, said the need amounting to $44bn was slashed to $29bn last year, and only about half was ever funded by year’s end.
This year, the need was pegged at $33bn, of which $23bn is being dedicated to the “most life-threatening needs”.
“For scale, this is equivalent to roughly 1 percent of annual global military expenditure,” the report noted.
Removing politics from humanitarian funding
Some 239 million people are estimated to need aid in 2026, but only a third of that figure may actually receive it, the report said.
Public health financing, the authors wrote, cannot be part of “statecraft”.
“A system governed in this way will not self-correct: exclusion becomes normalised, accountability is reduced to compliance, and humanitarian health becomes increasingly selective and unreliable, with large-scale need left outside response plans.”
Gaza is a prime example, where ongoing Israeli air strikes and ground attacks, despite the October ceasefire, have left more than 172,000 Palestinians wounded.
‘I think Gaza was a huge turning point, where people said enough is enough’
– Paul B Spiegel, Johns Hopkins Center for Humanitarian Health
At least a third of them are living with life-altering injuries, the UN has said.
Nearly 600 aid workers have been killed by Israeli fire since the 7 October 2023 Hamas-led attacks on southern Israel, and only 14 of the 36 hospitals in the enclave are partially functioning.
In total, over 72,500 Palestinians have been killed in the war on Gaza, which has been recognised by the UN, scholars and human rights organisations as a genocide. However, a July 2024 report in The Lancet put the death toll at over 186,000.
Israel – backed by the US – has tied its approvals for humanitarian aid trucks to demands it has outlined for Hamas to fully disarm.
“I think Gaza was a huge turning point, where people said enough is enough,” Spiegel told MEE.
Because of the politicisation of aid, the report emphasised, “international law is stripped of consequence, humanitarian principles are selectively applied, and survival is deliberately rationed”, leading to a system devoid of principles and “no longer fit for purpose”.
“The idea is to remove as much as possible politics from humanitarian funding and focus it on need,” Spiegel said.
Radical overhaul
The recommendations in the report, the authors insisted, are “not a menu of options” but rather “a coherent framework designed to be operationalised, measured, and enforced, explicitly accounting for political resistance and unequal power dynamics”.
The change cannot be incremental, they said – it must be part of a long-term overhaul.
It starts by shifting power away from lawmakers and leaders within the aid delivery system over to local communities instead, where aid recipients can also be decision-makers.
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International aid organisations should justify their involvement and operate with clear exit timelines, transferring authority to local leadership, the report recommended.
“There are too many UN agencies in humanitarian response,” Spiegel told MEE.
“They fight amongst themselves [and] compete, so we’re suggesting…there should be one solitary unified UN agency for humanitarian emergencies that’s slimmed down, that’s only for operations.”
The report also recommended establishing a “Global Health Protection Alliance” to prevent attacks on healthcare infrastructure and end impunity in this area.
Health outcomes such as preventable deaths and continuity of care, it argued, should be used as measurable indicators of compliance with international law.
The authors further urged the creation of an independent, global, pooled humanitarian fund insulated from donor politics and the expansion of direct cash assistance to affected populations to bypass problematic aid delivery systems.
The right to health, the report said, must be the central rule guiding humanitarian decisions.
“I think we have an opportunity, perhaps even a once-in-a-generation opportunity, because of what’s happening, both geopolitically and because of the massive reductions in funding, that change will come voluntarily, but will be forced upon everyone,” Spiegel told MEE.
“Our goal is to try to find [and] try to provide a pathway to make it so it’s transformative.”
