The crisis currently unfolding on Sulawesi, Indonesia is an international tragedy with a death toll already rising above 1000 with hundreds more missing. Initially struck by an earthquake with a tsunami following soon after, it has also been victim of a volcanic eruption. These natural disasters have created an emergency situation which is not helped by the remoteness of some of the areas effected. And yet the Indonesian government has been reluctant to accept aid and continues to refuse forms of foreign aid.
This article is not going to criticize the Indonesian government’s actions nor is it going to hypothesize on why they are making the decisions they are. On the other hand, this does introduce an interesting article around government sovereignty in crisis and difficult access. This is not a new issue with various aid groups having restricted access (see MSF – Pakistan 20131 , Merlin – Chechnya 20052, ICRC – Syria 20163, amongst others).
Access is a key issue in humanitarian health care for a variety of reasons. First, the practicalities of delivering good quality healthcare require sufficient access to populations in need with adequate equipment. Secondly, healthcare worker safety does depend on appropriately negotiated access agreed by all parties. Thirdly, the ethical principle of neutrality relies on well negotiated access.
This leads us to a difficult question. How can healthcare organizations provide good medical care in situations where important national actors (either governments, rebel groups, or otherwise) restrict access or actively target healthcare provision (South Sudan – 2016 provides a chilling example of the latter4)? This is an interesting question that NGOs in particular have been debating for a while and a few general strategies have appeared.
The first is any access is acceptable. This is underlined by the theory that any access is an improvement on no access at all. With this method NGOs avoid criticizing or reporting on issues in the crisis country. Additionally, this means accepting restrictions placed on the operations by the controlling power in the host nation. However, adopting this approach does not mean that the NGO won’t continue to negotiate for better access.
A second approach is pushing for all possible access and trying to work around restrictions. This would involve negotiating with all groups (both “good guys” and “bad guys”) in order to get a broad base of access including in non-governmental controlled areas. This can go one of two ways: either the NGO gains access to a larger area of country than if they engaged exclusively with governmental forces, or the NGO alienates one or more of their negotiating partners and loses access. The success of this varies depending on the skill of the negotiators, the reputation and history of the NGO, and the situation in the country.
Thirdly, an NGO can try to gain access by circumventing restrictions. This theoretically would mean defying previous negotiations. This is possibly the riskiest method as it can lead to an NGO not being recognized as an independent healthcare provider and instead turn it into a target. Additionally, it can allow that NGO (and its members) to bear heavy criticism about action, be denied assistance, and left out of the loop in bigger scale decision-making.
As easy as it may seem to pick an approach that suits your moral compass, things (as usual) aren’t as simple as they seem. Other factors that come into play are the safety of aid workers (something that weighed heavily on MSF’s decision to leave Somalia in 20135), the reliance that NGOs may have on in country resources (for example, if terrain is difficult to access), and the geopolitical situation of the area (in a tightly controlled nation it is practically unfeasible to operate with governmental permission).
All of these things reinforce the idea that negotiating access isn’t just an early step in providing humanitarian assistance but is in fact a vital one. The difficulty of working in a nation with a hostile government may be neutralized through solid negotiation. Sometimes it may be impossible to negotiate the access you want. The current example of Indonesia demonstrates this by the steady acceptance of foreign aid, however being selective of what aid they are willing to receive.
Author Details: Dr. Eliot Hurn, Foundation Year 2 County Durham and Darlington Foundation Trust.