The localisation of humanitarian response to conflict and displacement: a scoping review from a health systems perspective

Abstract

Introduction

The Grand Bargain Agreement at the 2016 World Humanitarian Summit emphasised the need to reform the humanitarian system. Central to these reforms were commitments to localise humanitarian assistance by increasing funding and decision-making for local and national responders and shifting control away from international actors. Localisation has the potential to improve the operational effectiveness of humanitarian assistance, strengthen local health systems and empower affected communities; however, progress has been slow. We aimed to identify the barriers, facilitators and outcomes of localised humanitarian health response for populations affected by conflict and displacement.

Methods

We searched six academic databases for empirical studies published between January 2016 and May 2024 describing localised or locally led health organisations, workers or service delivery for populations affected by conflict and displacement in low- and middle-income countries. We adopt a health systems perspective and results are presented as a narrative summary using the WHO Health System Building Blocks framework.

Results

Of the 48 included studies, 32 used qualitative methodologies. Efforts to localise humanitarian responses were hampered by multiple challenges relating to funding, leadership and relationships with international actors. Locally led humanitarian response improved the coverage, reach and responsiveness of health interventions, as well as the speed and efficiency of service delivery in conflict and displacement settings. However, there was little evidence of an increase in the meaningful participation or empowerment of affected communities and other local actors. Instead, international actors leveraged these operational advantages while retaining control over funding and decision-making. This dynamic increased workforce stressors for local staff and undermined local leadership and structures.

Conclusion

For genuine localisation to be achieved, the humanitarian system must foster equitable partnerships and funding mechanisms that empower local organisations and address the structural barriers that perpetuate their exclusion.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Localisation aims to improve humanitarian response and empower local actors; however, progress has been slow. Empirical evidence on its practical impact on humanitarian health response remains sparse.

WHAT THIS STUDY ADDS

• This review confirms that localisation can improve operational effectiveness but often remains an extractive process, falling short of Grand Bargain commitments to shift power and resources to local actors.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• To address persistent power imbalances and funding inequities in localisation, humanitarian workers and organisations from the Global North must move beyond tokenistic approaches and foster equitable partnerships, prioritise direct support for local actors and divest themselves of political, financial and epistemic power.

Introduction

The 2016 World Humanitarian Summit sought to reform the humanitarian system based on an international consensus on the need to improve the system’s effectiveness, efficiency, legitimacy and inclusivity.¹ The humanitarian system is dominated by a network of donors, states and international non-government organisations (NGOs) from the Global North and centred around the United Nations (UN) system, who control resources, set priorities and establish humanitarian principles and practices.² Global health institutions, research and decision-making remain concentrated in the Global North and the humanitarian system reproduces colonial legacies by marginalising humanitarian actors and affected communities in the Global South.^{3 4}

Central to the reforms proposed at the Summit were commitments to the localisation of humanitarian assistance. Through the ‘Grand Bargain’, donor governments and international agencies who collectively controlled over 95% of humanitarian funding agreed to prioritise ‘greater support for the leadership, delivery, and capacity of local responders and the participation of affected communities in addressing humanitarian needs’.⁵ This commitment to localisation, coupled with a ‘participation revolution’, aims to foster the meaningful representation and leadership of local responders and make humanitarian response ‘as local as possible and as international as necessary’.⁶ By establishing local and national actors as ‘the primary determinants of how resources are invested and how crises are prepared for and responded to’,⁷ localisation seeks to facilitate the transfer of power away from international actors towards those directly affected by and responding to crises.

Two primary objectives underpin the discourse of localisation within the international system.^{8 9} First, it aims to enhance the operational effectiveness of humanitarian response. By leveraging local knowledge and resources, local and national actors could provide services that better reflect the needs of affected communities, improve programme coverage and reach and deliver more efficient, timely and sustainable humanitarian response.10,12 Second, localisation has been promoted as a form of political justice that supports the empowerment of local communities.^{8 9 13} Moving away from an international humanitarian system led by governments and agencies from the Global North could offer an alternative to the ‘hegemonic directionalities of aid’, which have traditionally involved the North-to-South movement of expertise, decision-making and resources.¹⁴

Despite becoming a goal of humanitarian system reforms, progress towards localisation has been limited. There has been a persistent failure to increase direct funding to local and national responders, limited progress in local leadership and no substantive increase in the role of affected communities in the design and delivery of humanitarian assistance.¹⁵ While international policies encourage localisation, practical and financial support to local leadership is insufficient and few incentives exist for international organisations to reform practice.¹⁵ Questions remain regarding how to effectively implement local–international cooperation and how best to support locally-led responses.¹⁶ Further, a growing body of literature suggests a disconnect between the experiences of local organisations and the justifications for localisation made by the international community.17,19

Efforts to localise humanitarian assistance have been constrained not only by funding and structural barriers but also by the problematic ways in which the ‘local’ is conceptualised. The localisation discourse has perpetuated a local–international binary that obscures the diversity of actors involved in humanitarian response.²⁰ This binary constructs local actors as a fixed category defined by their geography, size and perceived authenticity while positioning international actors as impartial, professional and technically competent.²¹ The Grand Bargain’s definition of local and national responders excludes diaspora organisations and informal community networks that play a critical role during crises.²² In practice, organisations labelled ‘local’ differ widely, from national branches of large international NGOs to smaller community-led and refugee-led groups, each with varied levels of recognition, influence and access to resources.²¹ In displacement settings, affected communities and refugee-led organisations may no longer be geographically local, and ongoing conflict and government restrictions can prevent communities from formally organising or leading humanitarian response.^{23 24} The term ‘local’ is strategically negotiated and shaped by broader historical and political forces that determine who is seen as legitimate, who is marginalised, and whether meaningful shifts in power and resourcing occur.²⁵

Health systems in humanitarian settings affected by conflict and displacement face extreme challenges due to economic and political instability, weakened governance structures, damaged infrastructure, disrupted supply chains and the loss of healthcare workers.^{26 27} These systems often operate as hybrid models, characterised by a mix of local NGOs, national actors, international NGOs and UN agencies, which can result in fragmented and poorly coordinated service delivery, the diversion of resources from national health systems and the implementation of interventions that fail to consider local context or needs.28,30 Despite the increasingly protracted nature of humanitarian crises, short-term programme cycles and funding models persist, with implications for the sustainability of services and limiting opportunities to strengthen the local health workforce.³¹ In these contexts, localisation and the promised ‘participation revolution’ could present an opportunity to strengthen health systems, empower local communities and foster more appropriate health programming.

To date, localisation has primarily been examined from the perspective of international actors and focusing on operational effectiveness. A gap remains between the rhetoric of localisation within the internationally-dominated humanitarian system and real-world examples of effective locally led practices and partnerships.^{32 33} Two literature reviews of humanitarian localisation identified a predominance of grey literature produced by international NGOs and a limited number of empirical, peer-reviewed studies.^{34 35} Recent systematic reviews have highlighted the importance of localisation in specific aspects of humanitarian response, including gender-based violence (GBV),³⁶ neonatal care³⁷ and refugee governance.³⁸ However, a better understanding of what localisation means in practice is required to identify the obstacles to implementation and the potential for localisation to strengthen local health systems.^{33 39}

This scoping review aims to identify and critically examine the emerging literature on humanitarian localisation from a health systems perspective. Specifically, this review draws on empirical literature to:

1. Describe the role of local actors and models of localisation employed in humanitarian health response for populations affected by conflict and displacement in low- and middle-income countries.

2. Identify the barriers, facilitators and outcomes of locally led or localised humanitarian response in these settings.

Methods

We adopted a scoping review methodology to examine the extent and nature of available literature around the term ‘localisation’, an emerging concept in the humanitarian field.^{40 41} The review follows PRISMA-ScR (Preferred Reporting Items for Systematic review and Meta-Analysis extension for Scoping Reviews) guidelines and a review protocol was preregistered (www.osf.io/rsztm).

Eligibility criteria

Study eligibility criteria were developed around three elements: concept, participants and context.⁴²

Concept

We adopted a broad definition of humanitarian localisation to include any efforts to shift ‘tasks, power, and funding from large international actors and donors to national and local responders’⁴³ or any humanitarian response where ‘local and national actors are at the centre and are the primary determinants of how resources are invested and how crises are prepared for and responded to’.⁷ We conceptualise localisation as an umbrella term encompassing a range of practices and responses, including both top-down efforts to strengthen local ownership and models that originate within local communities.³⁴ This includes both ‘localised’ humanitarian response led by international actors and ‘locally led’ response, which captures the work of local actors themselves, including communities, refugees and the diaspora, and may occur independently of formal localisation efforts.

Participants

The definition of local and national actors outlined in the Grand Bargain agreement includes both state and non-state actors operating at local, subnational or national levels.²² Given the contested nature of who counts as local, we broadened this definition to reflect the diversity of actors involved in humanitarian response. This approach aimed to acknowledge the complex realities of humanitarian response and avoid reinforcing existing hierarchies within the humanitarian system. We recognised that the term local captures a range of organisational types, including national branches of international NGOs, national NGOs, subnational health agencies and community-, activist-led and refugee-led groups. Despite their exclusion from the Grand Bargain, we additionally included diaspora organisations due to their important role in providing cross-border assistance in humanitarian settings where government restrictions or insecurity prevent them from maintaining headquarters in the affected country.

Context

Eligible articles were those describing organisations and actors providing humanitarian health assistance to populations affected by conflict and displacement in low- and middle-income countries. We adopted a health systems perspective and sought to identify studies describing all organisations, institutions, resources and people who work to improve health within the humanitarian system.⁴⁴ Articles were included if they described health organisations, financing, workforce, service delivery, outcomes or risk factors, acknowledging that this may include studies beyond the humanitarian health cluster, such as WASH (water, sanitation and hygiene), nutrition and protection.

Search strategy and screening

Electronic database searches were conducted in May 2024 in MEDLINE, EMBASE, Web of Science, Global Health, Scopus and PsycInfo. Search terms included a combination of keywords and index terms, with adaptations for each database. The search strategy was built around two concepts: (1) populations affected by conflict and displacement and (2) ‘localisation’ (see online supplemental appendix). This was supplemented with a search of Google Scholar and backward-forward citation screening of all included studies and relevant reviews. References were imported into a Covidence database for deduplication and screening. Three authors (MM, ED and GK) independently reviewed titles and abstracts, followed by full-text articles, according to the screening criteria (table 1). Discrepancies were resolved through discussion.

Table 1. Screening criteria.

Inclusion criteria	Exclusion criteria
Localisation or locally-led humanitarian response.	No description of locally led or localised response.
Health organisations, financing, workforce, service delivery, outcomes or risk factors.	Studies not directly relevant to health (eg, education, camp management, livelihoods).
Population affected by conflict and displacement in a low- or middle-income country.	Displaced and conflict-affected populations in high-income countries.
Published since January 2016 (coinciding with commitments to localisation at the 2016 World Humanitarian Summit).	Published before 2016.
Peer-reviewed research.	Grey literature.
Primary studies, describing empirical research of any study design.	Commentaries, editorials, systematic reviews.

Data extraction and summary

Data were extracted to a charting table, which included the following elements: author, publication year, study design, study setting, affected population and the roles and types of local, national and international actors involved. Qualitative data relating to the role of local actors and the barriers, facilitators and outcomes of localisation were extracted using NVivo software. First order (primary data) and second order (authors’ summaries of primary data collection) data were extracted and open-coded into categories aligning with the research aims: barriers, facilitators and outcomes. These codes were then organised against the two broad objectives of localisation: (1) operational effectiveness (structured according to the six elements of the WHO Health System Building Blocks framework: leadership and governance, health service delivery, financing, health workforce, medical products and technology and health information systems)⁴⁴ and (2) participation and empowerment. Results are presented as a narrative summary. Consistent with scoping review methodology, no quality appraisal was conducted.⁴⁰

Results

In total, 2102 records were identified from database searches (figure 1). Following deduplication, 1074 records were title and abstract screened, 114 assessed at full text and 48 studies included in the review. These studies adopted qualitative (n=32), mixed methods (n=13) and quantitative methodologies (n=3). 18 studies described localised humanitarian responses for populations affected by the Syrian Civil War, six for displaced communities from South Sudan, five for people affected by conflict in the Democratic Republic of Congo (DRC), four for ethnic minorities from Myanmar displaced to neighbouring countries, another four studies for the war in Yemen and three studies for conflict-affected regions in Colombia (table 2).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Table 2. Summary of included studies.

First author and year	Country of research	Study design	Participants and settings
Ahmed63 2020	Somalia	Mixed methods	Humanitarian health and nutrition response for women and children in Somalia.
Akik46 2020	Syria	Mixed methods	Maternal, child and adolescent health intervention coverage, challenges and adaptations.
Al Adem54 2018	Jordan	Qualitative	Local and international supply chain collaboration in humanitarian response for displaced Syrians.
Alkhalil81 2022	Syria	Mixed methods	Analysis of humanitarian health aid alignment during the Syrian conflict.
Altare77 2020	DRC	Mixed methods	Health services for women, children and adolescents in North and South Kivu provinces.
Ataullahjan48 2020	Mali	Mixed methods	Delivering nutrition, and maternal and child health interventions in conflict-affected regions.
Bdaiwi67 2023	Syria	Mixed methods	Locally led efforts to rebuild the medical education system in Northwest Syria.
Bennet55 2017	DRC	Qualitative	National and international consortium providing sexual health and GBV services.
Betts68 2021	Uganda, Kenya	Qualitative	Refugee-led organisations responding to COVID-19.
Carruth47 2018	Ethiopia	Qualitative	Local participation in data collection and research in conflict-affected regions.
Chowdhury 2022101	Bangladesh	Quantitative	The involvement of local actors in humanitarian response for Rohingya people.
Dijkzeul58 2021	South Sudan, Uganda	Qualitative	A local–international partnership implementing food security interventions.
Douedari73 2019	Syria	Qualitative	Local health systems governance initiatives, solutions and challenges in Northwest Syria.
Duclos45 2019	Türkiye	Qualitative	The role of local actors in providing cross-border health services in Northwest Syria.
Duclos72 2021	Lebanon	Qualitative	Refugee healthcare workers providing healthcare to displaced Syrians.
Easton-Calabria69 2022	Uganda, Kenya	Qualitative	The role of refugee-led organisations during the COVID-19 pandemic.
Elayah60 2024	Yemen	Qualitative	UN and local NGO cooperation in humanitarian food assistance programmes.
Elkahlout18 2022	Yemen	Qualitative	Challenges and realities of localised humanitarian action in Yemen.
Fradejas-Garcia 2019	Türkiye	Qualitative	INGOs and local NGOs working remotely to provide assistance in Syria.
Frennesson59 2021	Multiple	Qualitative	International perspectives on localised logistic preparedness and obstacles to implementation.
Frennesson75 2022	Multiple	Qualitative	International logistics and supply chains experts’ perspectives on localisation.
Gidron70 2022	Ethiopia	Qualitative	Refugee-led organisations working with South Sudanese refugees.
Hillel80 2023	Multiple	Quantitative	Analysis of global trends in localised MHPSS funding.
Kallström82 2022	Syria	Qualitative	Syrian healthcare workers providing cross-border assistance from Türkiye.
Khoury52 2024	Multiple	Mixed methods	Syrian and international aid workers providing humanitarian assistance to displaced Syrians.
Kraft56 2019	Jordan, Lebanon	Qualitative	Two faith-based organisations implementing projects for Syrian refugees.
Krishnan76 2022	Bangladesh	Qualitative	Humanitarian healthcare providers working with displaced Rohingya.
Kuipers66 2020	Colombia	Qualitative	Local, national and international response in a conflict-affected, displacement-affected and disaster-affected region.
Ladadwa85 2024	Syria	Mixed methods	Local, national and UN agencies strengthening health information systems in Northwest Syria.
Lokot61 2024	Lebanon	Qualitative	A nationally led MHPSS coordination mechanism for displaced Syrians and Palestinians.
Mulder57 2023	Ethiopia	Qualitative	Collaboration between two international NGOs and local actors in Ethiopia.
Murdie86 2023	Multiple	Quantitative	Survey of international public health NGOs providing humanitarian assistance.
Nungsari71 2022	Malaysia	Qualitative	Refugee-led, community-based organisations working with displaced people from multiple countries.
Palmer83 2024	Uganda	Qualitative	The experiences of South Sudanese refugee health workers.
Pincock33 2021	Uganda, Kenya	Qualitative	The interactions between international NGOs and refugee-led organisations in Kampala.
Piquard19 2022	CAR	Qualitative	Knowledge production within a local humanitarian organisation in the Central African Republic.
Raftery62 2023	Lebanon	Qualitative	A UN and government-led task force coordinating GBV services during a complex emergency.
Ramos-Jaraba65 2020	Colombia	Mixed methods	Multiple actors implementing maternal and child health interventions in conflict-affected regions.
Roborgh53 2023	Türkiye	Qualitative	Syrian medical–humanitarian organisations operating in Türkiye and Syria.
Roepstorff39 2022	Bangladesh	Qualitative	Local and international organisations working on the Rohingya response.
Singh29 2021	Multiple	Mixed methods	Case studies of sexual, reproductive, maternal and child health in 10 conflict-affected countries.
Tappis74 2020	Yemen	Mixed methods	Multiple actors delivering reproductive, maternal and child health services during the conflict in Yemen.
Toukan49 2023	Jordan, Lebanon	Qualitative	Women-led, community-based organisations responding to GBV among refugees.
Tyndall84 2020	Nigeria	Mixed methods	Multiple actors delivering reproductive, maternal and child health and nutrition services.
van Voorst50 2019	Multiple	Mixed methods	Humanitarian experts examining the practices of expatriate and national humanitarian workers.
White64 2022	DRC, Iraq	Qualitative	Local, national and international humanitarian WASH staff working in hygiene programming.
Wurtz79 2020	Mexico, Honduras	Qualitative	Local, faith-based organisations providing services to people fleeing violence in Central America.
Yamout78 2024	Lebanon	Qualitative	Experiences of Syrian ‘close-to-community’ healthcare workers during the COVID-19 pandemic.

CAR, Central African Republic; DRC, Democratic Republic of Congo; GBV, gender-based violence; INGO, international non-government organisation; MHPSS, mental health and psychosocial support; NGO, non-government organisation; UN, United Nations; WASH, water, sanitation and hygiene.

Models of localisation and the role of local and national actors

The included studies captured varied examples of local, national or community involvement during humanitarian crises, as well as differing interpretations of what constituted localisation or locally led response. Most studies did not describe specific models or processes of localisation. Instead, they described the lack of localisation as a barrier to effective programme implementation or as a critique of the humanitarian system as a whole. Nevertheless, the roles and relationships between local, national and international actors provided insights into how localisation, or attempted localisation, occurred in practice.

First, humanitarian projects are implemented with ‘localised’ elements while remaining internationally-led. International actors subcontracted project implementation to local organisations3945,49 or used remote management structures, where international staff managed projects in neighbouring countries or regions while local staff delivered services in conflict zones.4546 50,53 Although these projects were described as ‘localisation’, there was no transfer of decision-making power and projects tended to be short term, leaving local actors with limited opportunities for capacity building or organisational strengthening. Local staff frequently carried increased risk due to security threats in conflict-affected regions without adequate support or control over resources. Second, localisation was described in terms of partnerships and collaborations between local, national and international actors.54,58 These relationships included examples of bilateral partnerships based on organisational complementarity and the transfer of responsibilities and funding to national and local actors.^{18 59 60} While local actors typically still operated as implementing partners, these partnerships facilitated greater local involvement in data collection, needs assessments and intervention design. Coordination structures, such as GBV and mental health and psychosocial support (MHPSS) task forces within the humanitarian cluster system, provided opportunities for local leadership, better engagement with national actors and the gradual transfer of responsibilities over time.61,63 However, these partnerships often remained contingent on short-term, project-based subcontracting, reducing opportunities for local leadership and organisational financial security.^{19 48 49} Finally, multiple studies described locally led humanitarian response driven by national or community priorities and standing in contrast to top-down ‘localised’ processes where control remained in the hands of international actors. This included studies describing humanitarian efforts led by Ministries of Health and subnational health organisations,63,66 local health authorities in non-government controlled conflict zones,⁶⁷ local NGOs and refugee-led organisations.3368,72 Nevertheless, these locally-led responses still relied on external funding from international donors, the refugee diaspora^{45 53 67 70} and international faith-based organisations.^{56 58}

Barriers, facilitators and outcomes of localisation

The barriers, facilitators and outcomes of localisation are presented according to the two core objectives of localisation: operational effectiveness (structured using the six WHO Health System Building Blocks) and participation and empowerment (table 3).

Table 3. Summary of barriers, facilitators and outcomes of humanitarian localisation.

(1) Operational effectiveness
Leadership and governance	The displacement of healthcare workers undermines local organisational capacity.45 61 67 73
	In conflict zones, state actors suppress local NGOs and healthcare workers, limiting leadership opportunities.18 39 45 52 71 73
	Local and national actors are excluded from governance structures and leadership positions due to perceptions of corruption, political interference and the diversion of humanitarian assistance.18 45 48 50 54 62 74
	International actors are reluctant to relinquish control.3339 52 61 75,77
Health service delivery	Localisation facilitated by local actors’ ability to improve service access and coverage.1845 51 53,55 69 72 75
	Locally led efforts deliver more responsive, person-centred health services.48 51 60 68 72 78 79
	Locally led services struggle to maintain quality and safety when working in challenging settings or when forced to align with donor expectations.45 46 65 68 72
Financing	Humanitarian financing is not meeting localisation targets.80
	A reliance on short-term, project-based funding from international donors undermines local autonomy and capacity.48 54 60 67
	International donor inflexibility and restricted funding reflect a lack of trust in local actors.18 45 50 67 69
	Local organisations are burdened by audit cultures and donor requirements, with their legitimacy to donors determined by perceived ‘professionalism’ and ‘compliance’.49 50 53 57 70
Health workforce	Localisation constrained by capacity limitations of the local and national health workforce.46 58 59
	Local and national health workers are exposed to the greatest safety and security risks, and more occupational and workforce stressors.18 29 47 49 51 52 54 56 63 65 67 68 74 75 77 82 84
	Local and refugee healthcare workers are motivated by their sense of obligation to their community.29 45 52 65 72 78 82 83
Medical products and technology	Centralised or regionalised supply chains offer efficiencies over localised approaches.66 75 84
	Localised supply changes are hindered by poor quality medicines in local markets and limited access to controlled drugs.46 59 75
Health information systems	Health information systems in humanitarian settings remain ‘top down’ structures.85
	Inappropriate needs assessments and data collection within internationally led projects undermine data quality and lead to mistrust and confusion within communities.19 47
(2) Participation and empowerment
	Local actors are restricted to ‘on-the-ground’, subcontracted positions and are excluded from decision-making, reflecting persistent asymmetries of power between local, national and international actors.1819 33 39 51 52 54 57 61 63 69,71
	Participatory data collection and methods could improve local participation, although affected communities remained excluded.2939 47,49 56 64 76 86
	Equitable partnerships can enhance the reputation, skills and sustainability of local organisations.47 54 56 59 61 62 75

NGO, non-government organisation.

Leadership and governance

The displacement of clinicians, specialists and managers during conflict reduced the capacity of local and national organisations.²⁹ Refugee health workers and refugee-led organisations faced restrictions gaining professional registration in host countries⁶⁷ and grassroots governance structures lacked political recognition.⁷³ Refugee diaspora organisations in neighbouring countries faced government restrictions when providing cross-border health services⁴⁵ and refugee staff were excluded from humanitarian coordination mechanisms because they were not legally entitled to work.⁶¹ In conflict zones, state and de facto state actors frequently suppressed local NGOs¹⁸ and targeted healthcare workers and hospitals.^{45 73} Consequently, refugee-led organisations relied on informal networks and operated as ‘low-profile’ subcontractors to larger international actors,^{45 52 71} limiting opportunities for local leadership.³⁹ International actors were concerned about the ability of local staff to remain neutral and adhere to humanitarian principles due to religious, political or ethnic allegiances,¹⁸ although others challenged this view.^{45 50} This perception, alongside corruption, political interference and the diversion of humanitarian assistance by state actors, disqualified local and national organisations from unrestricted funding and leadership positions.^{18 45 48 54 62 74}

International staff and organisations were reluctant to transfer responsibilities and leadership to local and national staff,^{52 61} reflecting a lack of trust in local partners.³⁹ One local humanitarian worker reported that international staff ‘…want to retain control as much as possible… because it’s their business’.⁷⁵ International staff attributed this to restrictive policies and donor requirements, and the need for guidance on how to involve affected communities, national governments and local expertise in programme implementation.^{33 39 75 76} Excluding local actors from leadership resulted in duplication, poor coordination and fragmented service delivery^{48 64 66} and undermined the effectiveness of local solutions and systems.^{51 60} International staff were reluctant to make transformative changes without external pressure,⁷⁵ and government policies and legislation emerged as facilitators of localisation by compelling international actors to act. In Yemen, national policies required international organisations to partner with local actors,¹⁸ while in the DRC, the government introduced measures to increase international donor alignment with national health strategies.⁷⁷ However, in practice, governments lacked the power to impose restrictions on donors because, as one national medical officer noted, ‘the hand that gives is above the hand that receives’.⁷⁷

Health service delivery

Localisation was facilitated by international actors recognising the ability of local actors to enhance service access and coverage by leveraging established relationships, trust and legitimacy with affected populations to extend programme reach,1845 51 53,55 69 72 75 particularly to undocumented or ‘hidden’ refugee communities.^{54 55} Recognising these advantages, international NGOs invested in training and capacity-building for local staff because of their ability to improve access¹⁸ and overcome cultural, linguistic and political barriers to humanitarian assistance.⁵¹ International actors specifically partnered with local organisations who were embedded in local networks to provide more efficient, timely and sustained service delivery in conflict-affected regions.^{18 54}

Locally led services were also better aligned with the needs and preferences of displaced communities, improving health service satisfaction and responsiveness.^{48 68 72 78} Conversely, when local and national responders shifted programming to align with the priorities of international donors, the long-term needs of the population were neglected, especially when crises subsided and emergency funding dried up.^{48 63} Local and refugee health professionals worked with their communities to provide culturally appropriate and contextually relevant health services centred on the dignity and holistic needs of service users.^{51 60 72 78 79} For example, unregistered refugee healthcare workers served refugees who could not access care due to discrimination⁶⁸ and delivered services in patients’ native language, negotiated treatment costs and used informal referral pathways.⁷²

Quality and safety were highlighted as crucial considerations in locally led refugee services. Syrian refugee health providers, working outside national guidelines and without medical registration, used personal referral pathways and prioritised only essential treatments due to their patients’ financial constraints. Yet, they did not believe this compromised service quality or patient safety.^{68 72} In other settings, attempts by local organisations to align services with donor priorities or follow international actors’ decisions about how and where to implement interventions compromised service quality⁵³ and effectiveness.⁶⁵ Improving quality of care required long-term partnerships between local and international actors and consistent investment in staff training.^{45 46}

Financing

Two studies quantitatively tracked trends in localised humanitarian financing.^{80 81} These studies found that from 2017 to 2021 only 3% of MHPSS funding went directly to local or national organisations rather than through international intermediaries⁸⁰ and highlighted poor alignment between humanitarian assistance and local strategies during the Syrian conflict, despite some improvements over time.⁸¹

A reliance on international funding limited local organisations’ autonomy in decision-making and programme delivery⁶⁷ and instead forced them to align with international NGO funding conditions.⁵⁴ When funding was unavailable, local organisations prioritised selected services over comprehensive ones⁴⁸ or reduced programme scope and scale.⁶⁰ Established humanitarian funding mechanisms favoured short-term, project-based financing, which prevented long-term staff development or local leadership roles, particularly in protracted crises when the initial influx of humanitarian funding ended.⁴⁸ As a result, localisation was considered incompatible with a single project and instead required long-term funding, learning and collaboration.⁵⁸ By contrast, diaspora networks, such as Syrian NGOs supported through donations⁴⁵ or South Sudanese⁷⁰ and Somali⁶³ diaspora organisations, provided flexible funding streams to bridge gaps and sustain programme priorities when international support declined.

Restricted funding and donor inflexibility reflected a lack of trust in local actors from risk-averse international funders, especially in conflict settings where banking regulations and professional registrations had collapsed.⁴⁵ International funders were concerned about corruption and diverting funds to parties to the conflict.¹⁸ Weak governance structures and national institutions posed challenges for small local organisations attempting to manage large budgets and account for funds.¹⁸ Refugee-led organisations, in particular, reported being excluded from international funding mechanisms.⁶⁹ Donor requirements created audit cultures and inflexible bureaucratic arrangements that overwhelmed local partners, diverting focus from programme delivery and accountability to grant management and compliance.^{18 50 67}

To secure funding, local partners needed to imitate the values demanded by international funders. While local actors held legitimacy with affected communities due to shared experiences and cultural or linguistic proximity, their legitimacy to the international community and ability to attract international funding depended on professionalism, compliance, accountability and quality control.^{53 57} Local and refugee-led organisations were valued for their efficiency⁶¹ and ‘ability to shape themselves to the priorities and agenda set by donors’.⁷⁰ For smaller, refugee-led or community-led organisations, or those facing national restrictions on professional registration, meeting these requirements was challenging and resulted in exclusion from many funding schemes.^{49 50}

Health workforce

Localisation efforts were constrained by both perceived and actual limitations in local capacity, which was exacerbated by the displacement of the health workforce.⁴⁶ Project-based, short-term funding, remote management and the exclusion of local actors from decision-making resulted in ‘a bunch of scattered, random training from different organisations’⁴⁶ or ‘endless training (that) if you are then not implementing or using… does not bring you any added value’.⁵⁹ Focused capacity building, combined with long-term funding, facilitated successful localisation, strengthening trust between partners over time.⁵⁸

The improved access and reach achieved by locally led humanitarian response exposed local healthcare workers to safety and security risks. Local staff often operated in the most dangerous contexts, while international staff remotely managed projects from neighbouring regions or countries.⁵¹ Healthcare workers from local communities were specifically hired for their ability to provide services safely in conflict zones.^{63 65} However, despite their better understanding of the context and access to local intelligence, in some settings, local health workers faced a greater risk of detention, abduction and assassination.^{18 29 82}

Safety and security concerns were compounded by the loyalty and obligation local staff felt toward their communities.^{29 45 52 65 72 78 82 83} Syrian healthcare workers were ‘more committed to the cause’⁷² and described themselves as ‘the sons of this country’,⁴⁵ while in Colombia, national staff who ‘belonged to the community… were more deeply committed to the work and more willing to remain in service despite the difficulties’.⁶⁵ Despite having medical qualifications and visas to leave the country, many Syrian healthcare workers continued to provide services to their community out of moral, religious or patriotic duty.⁸² Similarly, South Sudanese healthcare workers were motivated by their personal stake in nation-building and health system strengthening.⁸³

While these obligations improved programme stability and continuity, they also put local healthcare workers at risk of burnout.^{18 56 67} Unlike large international agencies, local organisations could not offer support programmes to their staff.^{52 84} International organisations preferred employing local staff as they could be offered lower salaries and fewer benefits compared with international staff.^{54 68 75} Other workplace stressors experienced by local and national humanitarian staff included job insecurity and delayed salaries,^{47 67 77} the risk of legal repercussions or deportation if found practising without formal registration,⁷² limited professional development opportunities⁶⁷ and high staff turnover.^{49 74 77 84} These workforce challenges worsened when local and national organisations could not recruit additional staff due to the displacement of healthcare workers^{29 84} and could not match the salaries and conditions offered by international organisations.^{63 77 84}

Medical products and technology

While supportive of efforts to localise humanitarian response, some logistics experts described the need for centralised or regionalised approaches to supply chains and medical logistics. Coordinating supply chains at scale, such as within the humanitarian cluster system, was essential to avoid waste, duplication, inefficiencies and fragmented service delivery.^{66 75 84} Locally led supply chains faced difficulties procuring certain medicines, such as controlled drugs, in local markets.⁴⁶ Supply chain experts raised concerns about the quality of medical products and widespread counterfeit drugs in some regions.^{59 75}

Health information systems

Health data collection and management in humanitarian settings continues to operate in a top-down structure with limited involvement of local staff and communities, resulting in fragmentation and poor data accessibility for many health actors.⁸⁵ Without local leadership, needs assessments and response strategies could not appropriately guide programme design and implementation.⁸¹ Data collection and rapid assessments conducted by international actors and others from outside the affected community with a poor understanding of local culture and context reduced the validity and utility of findings and led to mistrust and confusion within communities.^{19 47} However, local expertise and community connections created opportunities for greater involvement of local, national and refugee organisations in data collection and response planning. For example, national staff were better positioned to gather real-time information and use local knowledge to guide programme design,⁶⁴ and refugee-led organisations were instrumental in virus tracking during the COVID-19 pandemic due to their connections within refugee communities, including those without formal registration.⁶⁸

Participation and empowerment

Local and refugee-led organisations remained restricted to ‘on-the-ground’ roles and were excluded from decision-making and capacity-building initiatives within the humanitarian system.^{33 69} Refugee humanitarian workers were ‘on the bottom rung of the aid ladder, connecting remote areas with NGO headquarters’⁵¹ and operated as efficient, subcontracted implementers of decisions made by international actors.^{52 70} The persistence of ad hoc, project-based funding to refugee-led organisations ‘may perpetuate, if not strengthen, the inherent imbalance of power’.⁷¹ International actors dominated humanitarian coordination mechanisms. When local and national organisations were included, they had limited decision-making powers.^{18 54 61 63} Local staff described a culture in which it is ‘inappropriate to contradict openly the views of external actors, particularly because communities and individuals fear the loss of support if they challenge expectations’.¹⁹ While international humanitarian workers could be frank and transparent with funders, national staff feared that admitting to implementation challenges or failures risked the withdrawal of funding.⁵⁰ Local staff were ‘empowered to follow orders’,⁵⁷ reflecting the dominant organisational culture in the humanitarian system, which treated local staff as inferior¹⁸ and was ‘only paying lip service to localisation, with little action to follow’.³⁹

Participatory data collection and research methodologies offered opportunities for greater community involvement and negotiation within the humanitarian system. However, affected communities remained excluded from the institutions and processes that govern and design interventions.⁴⁷ Local organisations with established relationships based on trust and respect were better placed to increase participation.⁵⁶ Inclusive approaches to community engagement placed service users at the centre of service delivery and ensured programming reflected community preferences and needs.⁷⁶ Despite an increased proportion of local staff in international NGOs, local populations were routinely excluded from decision-making.⁸⁶ International NGOs often arrived in humanitarian settings with ready-made interventions and predefined geographical scope without the involvement of local communities, NGOs or state actors.^{29 39 48 49 64}

Successful examples of partnership working facilitated localisation and strengthened local organisations. Participation in internationally funded consortia enhanced local organisations’ credibility and reputation, potentially leading to longer-term sustainable funding through successful grant applications.^{54 56} Medical supply chain experts noted a shift from top-down to bottom-up approaches, with national actors increasingly gaining control over humanitarian resources.⁵⁹ Similarly, locally led coordination mechanisms encouraged local leadership and incorporated local expertise into programming.^{61 62} Locally led humanitarian responses presented some opportunities for community empowerment through economic engagement, such as directly employing locals and members of the affected community^{47 54} and sourcing medical products locally.^{59 75}

Discussion

This is the first review to examine empirical examples of localised humanitarian response from a health systems perspective. Previous reviews have been dominated by grey literature published by international NGOs, which cannot be verified for rigour or transparency, as well as academic commentaries and editorials.^{34 35} Our review identified examples of humanitarian partnerships and locally led practice from multiple regions, conflicts and displaced populations. Despite a growing academic literature, the findings suggest that efforts to localise humanitarian response have failed to meet the Grand Bargain’s objectives.

Humanitarian localisation can be understood through two primary dimensions: operational effectiveness and power.^{8 9} The identified literature confirms that locally and nationally led humanitarian response can improve operational effectiveness, even when access to secure, direct funding is limited. Increased health service reach and coverage, more efficient and sustainable programming, and more responsive, context-specific services were attributed to the trust and legitimacy that local actors hold within affected communities, based on shared experiences and knowledge of local language, culture and everyday realities. However, in many cases, this remained an extractive process. International agencies leveraged these strengths while retaining control over funding and decision-making. This dynamic undermined local structures, created administrative burden and increased the risks borne by local healthcare workers. We found few meaningful examples of a shift in power, resources or funding, no acts of ‘self-determination’⁸ or ‘political justice’,¹³ and little evidence of the transformation promised as part of the Grand Bargain agreement.

Trust was an overarching theme of this review. Multidirectional mistrust between humanitarian actors has previously been described as a critical obstacle to humanitarian localisation.³⁹ International actors mistrust national actors due to perceived corruption or a lack of neutrality while demanding affected communities prove their suffering to receive assistance.⁸⁷ This mistrust determines whether international actors genuinely transfer decision-making or used local actors’ connections to affected communities for their own agenda. Disregarding the skills and knowledge of local actors and affected communities limited opportunities for local leadership and resulted in services that were misaligned with community priorities and needs. Local humanitarian staff were reduced to efficient implementers of decisions made elsewhere. Previous studies have highlighted how trust can develop within small humanitarian networks at the interpersonal level,⁸⁸ a finding confirmed in our review. Equitable partnerships require time and investment in local staff and organisations, fostering trust between actors and strengthening local structures through meaningful leadership roles and fair resource allocation (see Recommendations, figure 2). However, the unstable and highly politicised nature of conflict and displacement settings makes building these relationships difficult.⁸⁸

Figure 2. Recommendations for strengthening locally-led humanitarian response.

The international humanitarian system has been accused of ignoring the colonial legacies and unequal power relationships that feed this ‘trust deficit’.³⁹ Overcoming mistrust requires a consideration of power^{87 89} and the one-sided vulnerabilities and uncertainties created by the inequalities of resourcing, safety and decision-making within the humanitarian system.⁹⁰ Compared with international or expatriate humanitarian workers, local staff experienced short-term contracts, salary delays and limited support while working in the most insecure settings with few opportunities for training and development. Previous studies have warned that tokenistic efforts at localisation could hide and perpetuate, rather than challenge, existing power imbalances.^{21 91} Short-term partnerships based on project-based funding and external decision-making undermine local autonomy and encourage competition rather than collaboration between local organisations. Internationally led responses with ‘localised’ elements, such as subcontracting and remote management, exclude local actors from decision-making or access to direct funding. These structures not only limit local ownership but also shift safety and security risks to local actors, who continue to advocate for genuine partnerships,⁹² highlighting the need for adequate compensation, psychosocial support and safeguards to reduce exposure to harms (figure 2).

Previous studies have described the ambivalent position of local responders caught between the conflicting expectations of international partners and funders.⁹³ Local staff are expected to implement projects efficiently, transparently and in accordance with the humanitarian principles of neutrality and impartiality while simultaneously leveraging informal networks and their legitimacy to affected communities. These ambivalent relationships were evident in this review, with local actors valued for their ability to meet internationally dictated expectations of professionalism, compliance, accountability and efficiency. Flexibly meeting these expectations and delivering services in conflict-affected regions resulted in preferential treatment and integration into the humanitarian system. However, these partnerships also diminished the agency of local actors pursuing their own objectives and excluded smaller, refugee-led organisations that could not meet donors’ administrative and financial expectations. Simplified donor processes are needed to ensure more inclusive access to humanitarian funding (figure 2).

These findings call into question whether technical reforms to an internationally dominated humanitarian system can address its inherent injustices.¹⁷ The extractive nature of global–local partnerships frequently fails to support local leadership or foster structures that have developed in the Global South. Instead, international actors instrumentalise local responders by shifting implementation and administrative tasks without sharing promised resources and funding.¹⁴ As a result, localisation can institutionalise poorly supported and, at times, mistrusted local humanitarian actors within the international humanitarian system rather than strengthening organisations and structures in the Global South.⁹⁴ A transformation of the humanitarian system would require genuinely recognising local actors and affected communities as designers and decision-makers of local solutions, the delivery of promised localisation funding and for international actors to divest themselves of political, financial and epistemic power.⁹⁵ A meaningful transformation should draw on the longer history of Southern-led humanitarianism and support locally driven responses that have operated outside or alongside the international humanitarian system since before the Grand Bargain agreement. This includes the decades-long provision of health services by community-led organisations in Palestine,⁹⁶ South-South cooperation in Latin America based on models of social justice-oriented health assistance⁹⁷ and community-led responses to the HIV/AIDS and COVID-19 pandemics in informal settlements in the Global South.^{98 99} These examples challenge the assumption that legitimate humanitarian response must flow down from international actors and offer alternative visions of solidarity and humanitarian health response grounded in local priorities and political commitments.

Limitations

Our search strategy may not have captured all relevant studies. This is in part due to the varied interpretation of localisation across the literature and the multiple approaches to ‘grassroots’, ‘refugee-led’ or ‘community-led’ humanitarian response. While this review adopted a broad definition of local actors and sought to avoid reinforcing existing hierarchies, the concept of the ‘local’ can oversimplify complex relationships between actors. Previous studies have criticised the local-international binary within the localisation discourse.²¹ This framing risks collapsing diverse local actors into a single category of humanitarian recipients or implementers and positioning international actors as impartial or authoritative. A strength of this review is its expanded definition of local and national responders to include diaspora organisations. In displacement settings, focussing solely on the geographical local overlooks the role of the transnational refugee diaspora in funding and supporting refugee-led organisations, as well as displaced communities themselves, who may not be recognised as legitimate humanitarian actors.¹⁰⁰

Our focus on health systems further narrows the scope of this review and excludes a wider body of literature on humanitarian localisation within camp coordination, education and livelihoods. Additionally, our findings identified more barriers than facilitators, likely reflecting that most included studies were not explicitly about localisation but rather focused on the challenges of health service delivery or programming in humanitarian settings. We also restricted our search to studies published since 2016 to align with international commitments to localisation. However, there is a much longer history of community-led humanitarian response and South-South cooperation before the localisation agenda. It is important not to overlook these efforts or to frame localisation as a top-down, internationally driven process. Rather, the focus of this review was to examine how formal commitments made in 2016 have influenced research and practice in the humanitarian system.

Conclusion

Despite recognition of the benefits of locally led humanitarian efforts, persistent challenges remain. While local actors can enhance operational effectiveness due to their established relationships and proximity to affected communities, prevailing power dynamics and funding models within the humanitarian system limit their autonomy and reinforce extractive relationships. The continued marginalisation of local actors from decision-making and direct funding, coupled with mistrust between international and local stakeholders, undermines the transformative potential promised by the Grand Bargain. The humanitarian system must move beyond tokenistic approaches by strengthening existing structures in the Global South and rethinking donor requirements. Fostering equitable partnerships requires long-term investment in local organisational capacity and autonomy, alongside efforts to mitigate the risks borne by local and national staff.

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.