ABOUT THE AUTHOR
Janice K. Kopinak, RN., BA., MHSc., MSc., has worked as senior manager, researcher and health advisor in bilateral, multilateral and NGO agencies in emergency, relief, rehabilitation, and development programs/projects in Africa, Asia and the Balkans.
Humanitarian aid represents a commitment to support vulnerable host populations that have experienced a sudden emergency, requiring ongoing assistance to maintain or improve their quality of life. Over the past 15 years the number of humanitarian agencies, private organizations, governments (taxpayers), corporations, individuals and other stakeholders have grown enormously. This group of diverse donors have differing mandates, values, goals, strategies, actors and activities, but most function under one universal humanitarian principle: to protect the vulnerable by decreasing morbidity and mortality, alleviate suffering and enhance well-being, human dignity, and quality of life. However, many stakeholders believe that humanitarian aid has been unsuccessful in delivering on these promises through lack of coordination and duplication of services. This results in a failure to meet the needs of those meant to benefit. Indeed humanitarian aid with its diverse mandates, roles, people, time lines and funding, as well as the absence of clear definitions to describe specific identities (purpose, principles), presents a chaotic and confusing image to the public, host governments and recipients, as well as ongoing challenges for agencies and aid workers. Since appreciable donor finances total billions of dollars annually, these critiques present serious credibility and survival issues to agencies that depend on donor funding in order to save and improve the lives of the vulnerable. It is for this compelling reason that it is important to deconstruct the roles of and linkages between emergency, relief and development aid, identify problems that impact effectiveness and sustainability, and also acknowledge progress and successes both past and present.
1. HUMANITARIAN AID: THE IDEAL
E/R represents a response to a serious and unexpected natural or man-made emergency that demands an immediate reaction to reduce suffering and loss of life in the short term. Aid workers must be skilled at rapid assessment and treatment under difficult environmental conditions at times compounded by violence and/or lack of adequate essential resources. Planning and actions are designed to produce rapid results through immediate treatment and life-saving activities provided by medical care, potable water, shelter, food, clothing and security. In sum, E/R is fast-paced, reactive, short-term, focused on meeting immediate basic needs and preventing morbidity and mortality. A causal relationship exists between the crisis, requirements for survival, treatment and outcome. It is this relationship that through the media largely defines aid to the public and in turn translates into generous contributions from governments and the private, public and corporate sectors.
R/D is multi-dimensional and proactive with broad, complex parameters that focus on the rehabilitation and development of a vulnerable population through addressing bio-psycho-socio-economic factors within the cultural milieu. Building capacity is a key component of development and can be defined as the transfer of knowledge and resources through mentoring, workshops, trainings, infrastructure development, etc. Sustainability is the ultimate goal of all development aid and is the ability of host country entities to continue to apply new and evolving capacities and sustain achievements through providing reliable resources generated from a country’s own efforts. Deep immersion in the culture and collaboration with the host government and other stakeholders by aid workers is necessary to identify and prioritize needs and set goals that will maintain/improve health and well being. Hence activities are targeted toward enabling positive outcomes for the target population through the provision of basic necessities, advice and mentoring with regard to health, education, equity, governance, infrastructure improvement and security. Long-term successful impact is sustained empowerment of the government, community and civil society to meet the population’s aspirations and needs, leading to an improvement in the quality of life without compromising future strategic plans.
Transition is a vital link between E/R and R/D and is carried out collaboratively between agencies and the host country. Information exchange between stakeholders pertains to the country mandate, strategies, goals, time frame and accomplishments (real and planned) and how activities and strategies can be smoothly blended to best serve the evolving needs of the target population. Transition must be flexible in response to changing situations on the ground that may require different services, personnel, knowledge and resources. In these respects E/R and R/D do not often move predictably in one direction but can move in opposite directions and at other times overlap. The underpinning that is vital to a successful transition is a seamless merging of all information from the outgoing to the incoming agencies and communication and collaboration in the case of an overlap (Fig. 1). Diverse definitions, concepts, institutions, politics, cultures, the policies and practices of donors compounded by capacity constraints of recipients, and the blurred distinction between E/R and R/D mandates and activities can challenge and at times sabotage a smooth transition. Although these issues are situation-specific, stakeholders who are willing to collaborate to support a flexible transitional model and understand clearly their role within it can effectively contribute to the establishment and maintenance of strong and effective linkages. 
In sum, E/R with its fast-paced, reactive interventions of short duration is in stark contrast to the R/D focus on long-term proactive capacity-building. Both measure achievements via results that point to progress but measurement differs greatly. Emergency aid concentrates on input, output and short-term outcome (relieving suffering, providing basic necessities and services, saving lives) while the R/D focus is on input, output, long-term outcome and impact to eradicate the root causes of vulnerability through ongoing research, monitoring, and analysis (Fig.2). However the preservation, maintenance and improvement of population health and quality of life is a first priority for both short and long-term strategies. This requires the provision of adequate resources to carry out assessments, identify priorities, and create and implement a plan of action.
2. ACHIEVEMENT OF THE IDEAL: THREATS
The flow of funding requires a high profile public image frequently fueled by exploitation of beneficiary vulnerabilities, consequently there is a tendency to emphasize weaknesses and threats and de-emphasize strengths that is, the more serious and numerous the problems the more likely the proposal will be funded. Conversely, once funding is disbursed donors expectations are that positive reports regarding progress will be forthcoming. Unfortunately, this expectation often encourages implementers to work on situations with positive marketable outcomes in order to ensure future funding, and creates a disincentive to tackle difficult, entrenched problems.  However field reports that stress primarily positive achievements to the exclusion of factual information, including ongoing struggles and lack of success, are at best dishonest since achievements in humanitarian aid are hard won and frequently result in poorly-met objectives or failed strategies. It is crucial that there be a balanced assessment of the target population since there is evidence that many beneficiaries despite being exposed to a difficult life situation possess admirable resiliency and coping skills.
There are currently no enforceable criteria outlining who can form an implementing agency. Hence it is important for a the donor to ensure that contracted agencies possess the legitimacy, appropriate background, experience, and an understanding of humanitarian principles and the host country culture and context. Prior to funding a proposal, donors must require information that clearly outlines the project or program goal and objectives, a detailed plan of activities, needed resources and the time periods required to complete the short or long-term activities (months to years). The donor must be made aware of beneficiary needs as well as what agency can effectively deliver the appropriate services (short- or long-term). Hence in order to ensure cost-effective quality service, donors must not only investigate agency legitimacy before approving proposals, but also encourage a balanced approach to assessment that recognizes strength, coping and resilience as well as challenges. Implementing agency accountability in honestly reporting outcomes can only be accomplished with donor support that includes acknowledgement and acceptance of ongoing challenges and partially-met objectives as well as celebration of successes.
Aid Disbursements and Management
Donor disbursements for beneficiary needs and related expenses rarely seem to be enough and the belief that incremental increases in donor funding will translate into more effective aid is a hotly debated issue and based on very little research. Some evidence indicates that large funding disbursements that are fungible and poorly tracked wastes resources, discourages population incentives, creates corruption and an unrealistic unsustainable economy, all with serious consequences for the host country.  Moreover, erratic and unpredictable donor disbursements including delayed funding or a pledge that does not translate into an actual contribution has serious consequences for a vulnerable population. Since needs are constantly evolving, flexible but predictable release of funds by the donor that are timely and sustained is vital, particularly in development, with its time frame for sustainable change that frequently extends beyond five years.
The funding disbursed to implementing agencies for direct beneficiary needs is frequently utilized for indirect start-up and ongoing administrative expenses such as salaries (expatriates, local), housing, food and transportation. It has been estimated that these latter expenses meant for beneficiaries can total almost half of the entire amount disbursed. On the other hand, it is difficult to confirm this claim since aid agencies tend to provide information on the total program cost rather than a specific cost breakdown, even though a correlation between the cost per client versus labor costs would provide more reliable information pertaining to efficiency. The current use of formula generalizations to fund host countries that have similar needs can be helpful but cannot illustrate fully the complexities and uniqueness of each situation. One size does not fit all when there are dramatic differences in culture, infrastructure, economic conditions and governance capacity. Furthermore regional specificities and related categories of services require a budget and accounting details that defy comparison.
Since a complete breakdown of the total investment in a project/program is often difficult and, in most cases, impossible to access there is a need for more research and transparency pertaining to project/program costs focused on value for money. In this regard, a first step toward enhancing transparency and accountability of all parties is through the recruitment of a competent financial officer familiar with the country, culture and aid industry, in addition to regular independent audits. Careful scrutiny of budgets throughout the life of the project/program will not only improve cost-effective services for beneficiaries but will reveal valuable lessons learned pertaining to the inputs that lead to short or long-term desired results. In this regard donors must fully recognize the differences between long and short-term aid in that the former focuses on root causes of poverty, morbidity and mortality and the latter on reducing immediate suffering and saving lives. The way in which humanitarian situations are individually assessed should determine the source of funding, the scale of resources allocated, the form of response, the planning time frame, and the way in which organizational roles are determined. Equally important is that donors and implementing agencies recognize that the recipient country possesses a vision that can best identify the needs and direction of programming, projected costs and the transfer of funds that will increase the possibility of success through mutual understanding, appropriate planning, policy coherence and governance issues. In sum, aid disbursements must consider all of the above factors in deciding who receives what assistance, when and how with clearly defined short and long-term categories that point to and support institutional arrangements for distributing resources appropriately and equitably.
The general belief that aid workers just have to be enthusiastic and empathetic in order to be effective frequently results in inappropriate recruitment of staff that lack suitable knowledge, experience and skills to make a positive contribution to project/program activities. An equally troubling situation is the recruitment of aid workers/volunteers with self-serving motives to experience the world, build a lucrative career or boost popularity.  These inappropriate recruitments often reflect negatively on the donor and the implementing agency and risk harming program management by disrupting team functions and service delivery. Furthermore recruits who lack the pertinent experience and knowledge have difficulty in maintaining a balanced viewpoint pertaining to the host country’s people, cultures, values, beliefs and infrastructure which can result in workplace stress, frustration and anger, a situation exacerbated by the stress of living and working in a country with different values and often devoid of the conveniences found in the developed world. A common coping mechanism is to cling to what is familiar, effectively cutting off the opportunity to acquire a full understanding of the host country and people within it. These dynamics often lead to destructive complaints about host country corruption, incompetence and lack of work ethic supported by the belief that the large amounts of aid have equalized the playing field and recipients just have to “pull up their socks” and do things the way they should be done. Such negative perspectives of the inexperienced aid worker frequently results in miscommunication and seriously impaired collaborative relationships that affect team function, the delivery of quality services and recipient capacity development.
An effective and timely humanitarian operation has the capacity to save thousands of lives even within an environment with difficult access to beneficiaries. To successfully accomplish the many and varied tasks necessary to deliver effective quality care requires professionals with management experience, diplomatic skills and the abilities to objectively assess the situation, prioritize needs and multi-task. The initial task of aid workers is to establish rapports with the national government, beneficiaries and other stake holders and in collaboration assess recipient needs, construct a plan that is culturally sensitive, equitable, affordable, feasible, and satisfies the mandate of the donor, a delicate balancing act indeed. Administrative responsibilities are to secure office space and to hire staff. It is the responsibility of the implementing agency to carry out a complete and thorough vetting of each expatriate applicant to ensure that standards will be upheld and front line workers are stable and possess the appropriate skill set, knowledge, experience and ethical motivation to deliver cost-effective services to the host country and the aid recipients.  Although the situation is quite different, the same caution applies when vetting and contracting local applicants for positions within the agency.
3. EFFICIENCY AND SUSTAINABILITY
Critics argue that even though projects/programs have multiplied exponentially, there is little proven substantial impact on changing the lives of people. This is a serious criticism in spite of the fact that it is more difficult to show project/program impact on health and social issues than in other program areas. For example it is much easier to assess and measure road building and water-wells that have definite budgets, starting and end points to completion than health and social issues that have biological, behavioral and emotional components that are in constant flux. Although there have been measurable gains across developing countries what has been missing is a systematic way to determine what kind of aid works best. Implementing agencies that are operational on the ground often argue that interventions, albeit poorly-measured, still do make a difference through the provision of basic life necessities and capacity-building which could otherwise not be provided. While this might be true in some cases, anecdotes prove very little and are often disregarded by donors who require reliable results in order to continue funding. Furthermore if there is inadequate information pertaining to the starting line and ongoing process, then endpoint analysis will reveal little useful information regarding achievements and lessons learned. Unfortunately, there can be problems to achieving what appears to be a simple and straightforward strategy. The first is approval of donor funding since time, cost and the necessity of personnel with special research expertise are added to the budget. The second challenge lies in the reliability of the baseline population figures (denominator). In many developing countries, reliable census figures are difficult to obtain due to capacity, compounded by poor access to rural areas that often results in sketchy and unreliable vital registration data including mortality, morbidity, births etc.
Results, as opposed to anecdotal information, point to successes based on indicators that are the road map to effective interventions over a specified period of time. In order to increase the reliability of results, a baseline study at the beginning of the intervention, surveillance throughout and statistical analysis at the end cannot be overemphasized for its contribution to overall project/program effectiveness. A baseline study that pinpoints the demographics, culture, health and lifestyle of the target population is an excellent beginning that can provide information on which to identify indicators, initiate interventions and measure progress through ongoing monitoring for the life of the project/program. Although acquiring donor funding and reliable data present formidable challenges, a convincing case to donors can be made by emphasizing that personnel with solid research skills can draw reasonable conclusions based on collated evidence and on levels and trends on which to establish a baseline. If this process is carried out by individuals with appropriate research experience, valuable information will be elicited that will far outweigh initiation of a project/program on conjecture alone and far outweigh the initial investment.
Results-Based Management (RBM) is a popular tool that measures and monitors progress through determination of how input, output, outcome, and impact contribute to short, medium and long-term results. It is unfortunate that frequently the framework and components of RBM, related logical frameworks and SMART objectives (specific, measureable, achievable, relevant, time-bound) are not well understood or agreed upon by implementers, a situation that results in a struggle to master the technical aspects that overshadows the context. If the instrument is the focus, then aid is reduced to a technical exercise in which beneficiaries remain peripheral to the process, results will be unreliable and resources wasted.
Rather than following the latest fad to measure progress no matter what the goal of the project or program, the aims based on beneficiary need and staff capacities ought to dictate the measure. What would be more beneficial is to determine the capacities of staff, and if it is found that implementing the popular measure will elicit unreliable results, then thinking outside of the box becomes a necessity. It appears that the simplest way to achieve this is to design a tool that will collect relevant and reliable data based on indicators but that staff can easily understand and feel confident working with. It is this kind of confident flexibility within the aid community that still needs to be further developed in order to obtain reliable results that lead to cost-effective projects/programs.
Exclusionary assumptions of implementing agencies, based on a failure to recognize and include the community in planning and delivering services, can push recipients into a dependent state and negatively impact confidence, building capacity and future sustainability. These outcomes prolong the need for donor resources- a troubling development if donor fatigue takes hold and aid is either drastically reduced or terminated. Conversely, over-inclusion in hiring the most skilled, knowledgeable, educated and capable members of the local population at salaries host countries cannot match results in decimation of essential services to the civil population. Furthermore, as agencies compete for the brightest and most skilled workers, salaries become increasingly inflated, as do aid budgets. When aid is reduced or withdrawn, the inability on the part of the host government to sustain the unrealistic high salaries often results in brain drain as professionals abandon the country to work in developed countries that are experiencing staff shortages. In this rather peculiar turn of events, developed countries are giving aid with one hand but robbing host countries with the other by siphoning off their most precious resource of trained professionals.
Another unintended consequence that negatively impacts effectiveness pertains to the large amount of aid that flows into developing countries and contributes to almost instantaneous growth in all sectors, causing serious inflationary and cultural disruptions. These disruptions can occur short-term in an emergency when hundreds of workers arrive on the scene with personal and administrative needs, but can also be disruptive in the long term as expatriate workers continue to contribute to the economy. While large amounts of aid are a positive force to the host countries and its people through employment generation and increased consumption, the creation of a false economy can be disastrous to recipient government sustainability strategies when donor money is reduced or withdrawn.
In order to avoid the traps presented by overly exclusionary and inclusionary tactics, a balanced approach must be achieved based on collaborative strategies that tackle these issues head on with the host country and other stakeholders. In this regard, an increasing number of donors now collaborate with recipient countries to set salary scales in line with what would be earned at the same or similar jobs in-country, and to encourage building a structure that can be sustained when aid is reduced or no longer available. In addition, stakeholders and host governments work together to create a realistic staged plan for reduction/withdrawal of resources that will ensure that there will be country cost-effective strategies in place for strong and continuing independence that will prevent the country from falling into an unsustainable position when aid is withdrawn. Tracking these strategies over time will reveal their effectiveness, but both are aimed at ensuring that countries will be placed in a position of strength (in terms of capacity and finances) to assume future responsibility.
4. LINKING RELIEF, REHABILITATION/RECOVERY AND DEVELOPMENT
Linking emergency/relief, rehabilitation/recovery and development (LRRD) is a concept that can be traced to the international policy-related literature over 20 years ago. The basic justification for LRRD is simple, sensible and appears to be theoretically logical and necessary in that better development can reduce the need for future E/R, and better E/R smoothes the transitional path to better development. Hence, the goal should be to structure aid in ways that will promote the smooth integration of these categories within a ‘living’ framework in order to enhance performance, deliver quality services and reduce costs (Fig. 3).
Although the LRRD concept is broadly endorsed by many policy-makers to connect short and long-term measures, there remains a lack of consensus on how best to translate the theory into practice. Implementation of LRRD requires knowledge and skills pertaining to time, scope and agenda that are context specific and not readily interchangeable. Hence activities that may not fit neatly into one category or another can create overlaps and/or significant roadblocks. It is this situation that has resulted in a confusing and unproductive debate about where activities should be placed and accounted for within either a linear or a contextual model to improve alignment.  A related debate pertains to the imposition of a ‘one size fits all’ LRRD time frame that fails to recognize unique situations, events and environments and the importance of a good fit with all involved players including headquarters, field staff, donors, national and local governments and other stakeholders. Promoting transition at the most appropriate stage requires flexibility that will accommodate the unique nature of each situation, and successfully achieving this continues to present a particular challenges in policy, operational, and funding terms. To complicate matters further, donors generally do not recognize the broader picture and tend to fund projects/programs as separate entities (‘silos’), a practice that makes accounting easier but results in financing gaps and ‘stop-go’ services that are inconsistent with comprehensive transitional models such as LRRD.
First and foremost, a common understanding of the nature, scope and practical relevance of LRRD is a requirement for successful implementation. The time and skill required to ensure resolution of the above issues lies in stakeholder collaboration, timely, reliable donor short and long-term funding, a strong in-country presence and recruitment of skilled staff that possess the required knowledge and will remain long enough to provide an element of continuity. In spite of increasing commitments to LRRD, the complexity of putting commitments into practice and the bureaucratic and administrative constraints pertaining to different categories of funding continue to undermine many strategies. Nevertheless the ongoing development of LRRD is a worthwhile strategy that will increase the effectiveness of aid both now and in the future. While there is a vast difference in the modus operandi of E/R and R/D, each is costly and can be disruptive to economic and social development, resulting in often-overwhelming bureaucratic structures and procedures. Hence a first step is to promote cooperation and collaboration between stakeholders by emphasizing the service and cost effectiveness that can be gained through the use of a flexible transitional model that will enhance service and cost effectiveness for beneficiaries and donors.
5. THE GLUE THAT HOLDS IT ALL TOGETHER
Four terms that are frequently used in humanitarian aid to describe a common, united effort, partnership or harmonious purpose are cooperation, coordination, collaboration and communication, all vital to identifying and prioritizing interventions and shared visions that will result in increased beneficiary well-being and quality of life. Although all four characteristics are vital to efficiency between stakeholders and host countries, communication represents the most difficult but single most important task faced in the daily work of host countries and stakeholders to deliver cost-effective services (Fig. 4). However, quality information exchange at the verbal and/or behavioral levels is doomed to fail in the absence of shared trust, respect and values. The many diverse mandates that add to the complexity of successful communication require ongoing patience, diplomacy, transparency, listening, clarifications, confidence and lack of assumptions. In turn, these skills necessitate characteristics that include experience, academic preparation, a clear understanding of the program objectives and of humanitarian aid at the micro and macro levels. While poor communication risks working relationships (potential or ongoing) and impedes progress toward meeting objectives, quality communication has ongoing challenges that have to be assumed by every stakeholder individually and within a consortium in order to improve and maintain the effectiveness of aid.
Although humanism is recorded in the earliest annuls of history, organized humanitarian aid began with the rebuilding of Europe post-World War II, and has been characterized by constant evolution and attempts on the part of all players to tame a fast-moving target. The aid industry is still struggling not only with some past, unresolved issues but equally with many new challenges. Although governments, agencies, organizations, corporations and aid workers are running as fast as they can, in the current ballooning aid industry it is extremely difficult to keep on top of fast-moving events. Existing challenges include a failure to support and generally include local stakeholders due to insufficient analysis of local situations, culture and capacities before program implementation and a lack of clear transition and exit criteria strategies. Moreover, a silo approach to aid, with minimal inclusion and coordination of crosscutting issues such as gender, HIV/AIDS, governance, environment, poverty, etc., has eliminated program comprehensiveness and integration across stakeholder input. Coordination of projects and programs in a developing country is a daunting task and requires the support of all stakeholders to ensure that mandates are recognized without expensive duplication of services. In this regard, coordinators must be well trained in management and facilitation techniques and be action rather than process orientated.
The Good News
The goal of the Cluster Approach, implemented by the UN (2005) is to improve stakeholder and host country communication, cooperation, coordination and collaboration in order to minimize expensive duplication and conflicting activities through maximizing the exchange and flow of information. The specific aims are to strengthen partnerships and ensure more predictability and accountability in aid responses through clarification of the division of labor among involved agencies (national and international) and definition of their roles and responsibilities within key sectors. A Humanitarian and Emergency Relief Coordinator manages all incoming information, and cluster leads with relevant expertise and capacity are appointed to facilitate the work of each cluster that includes (I)NGOs and UN agencies and other stakeholders. This relatively new and expensive system encountered problems in the early roll-out stages, resulting in confusion and ill will among some stakeholders. However, according to evaluations carried out in 2007 and 2010 in selected settings, the initial investment has generated benefits over time that outweigh costs and shortcomings with initial opposition considerably lessened. Most importantly, the approach has significant potential for improvement of humanitarian aid and the well-being of beneficiaries. Some early findings are that coverage of needs has improved in some areas, gaps in aid are better identified with duplications reduced, peer review has increased the ability of humanitarian actors to learn and move forward, predictable leadership has led to improved coordination, partnerships have been strengthened and the planning and quality of funding proposals has been improved.  
Another important initiative to increase aid effectiveness has continued to evolve from its beginnings in Rome as the first High Level Forum, followed by the Paris Declaration on Aid Effectiveness, the Accra Agenda for Action and the Fourth High Level Forum in South Korea. All fora focused on main principles believed to be necessary to improve aid effectiveness including ownership of strategies by the recipient country, alignment of programs through donor support, harmonization to avoid expensive duplication of programs (coordination, simplification, sharing), results through monitoring and measuring, mutual accountability of donors and recipient countries and the control of funding be managed by recipient countries, be predictable and accountable. In sum, the Declaration represents a commitment from all signatories to uphold these principles in order to increase the positive impact of cost-effective aid by assisting developing countries to formulate their own plans according to national priorities, using their own planning and implementation systems. Hence in this rapidly-evolving field there are numerous strategies in progress, initiatives that represent hopeful beginnings toward improved, effective and sustainable aid.  
A broad view of humanitarian aid that looks beyond numerous critiques reveals past and ongoing successes made possible through the generosity of many private and public donors and the collaboration of stakeholders. For example, East and Southeast Asia were substantially dependent on Overseas Development Assistance (ODA) in earlier years, but were able to achieve remarkable growth in the 1980s and 1990s, effectively terminating their dependence on aid. Moreover, between 2005 and 2010 nearly half a billion people escaped extreme hardship and global poverty was halved. Twenty-two countries in sub-Saharan Africa are leading the decline in HIV/AIDS and there are 200,000 fewer deaths since 2004 due to policies focused on disease prevention and health promotion. Global immunization of children has steadily increased and targets in primary school education, use of mosquito treated nets, and polio eradication is close to realization. Fresh ideas from lessons learned continue to emerge. For example, a recent proposal by the British Government to look beyond debt relief for developing countries or incremental increases in aid and instead to provide assistance through increasing trade and removing barriers to increase GDP will decrease dependency, free up wealth, create enterprise and save more lives than either of the other two initiatives alone.  Finally, since poverty reduction is crucial to growth, and health is crucial to poverty reduction, the Millennium Development Goals (MDGs) a global cost-effective approach to address these issues holistically is one of the most important initiatives that places targets on a timeline. Although reaching targets has been uneven across countries, the support by many stakeholders has made an impressive impact on improving health and reducing poverty. 
International humanitarian aid has grown exponentially over the past sixty years in the number and variety of donors and aid workers, as well as the amount of money transferred to vulnerable countries for emergency, relief, rehabilitation and development. The delivery of effective and sustainable aid within the fast-changing world continues to present ongoing challenges to stakeholder communication and collaboration, keys to delivering quality services in a cost-effective manner. Although achievements in humanitarian aid amid ongoing change are impressive, there is a need on the part of donors, governments, aid workers, and the public to develop a clearer understanding pertaining to who does what, when, where and how. Clarifying differences between the emergency, relief, rehabilitation and development spectrum and the need to establish linkages as part of a flexible response to changes based on diverse roles, mandates, time frames and inevitable unfolding events is a vital first step. An understanding and acknowledgement of the unique attributes bonded together by a common motivation to communicate and collaborate will deliver the services that are needed to the right people at the right time and in the right place. To do less is tantamount to defining humanitarian aid as an insolvable problem, an attitude that is a disservice to host countries and to those stakeholders who generously contribute resources, knowledge and skills in order to improve the health and quality of life for vulnerable people worldwide.
Effectiveness and sustainability in humanitarian aid are not impossible dreams, and the achievement of acceptable and cost-effective outcomes in short and long terms is possible, as evidenced by successes in the past and present. The key to ensuring that successes continue and evolve lies in the understanding that humanitarian aid does not have an endpoint, but is a constantly unfolding process in which milestones mark the path paved by lessons learned.
 Common terminologies include humanitarian assistance, emergency aid, relief aid, development aid, development cooperation, and development assistance among others. For the purpose of this paper humanitarian aid describes the universal (caring and commitment to saving lives and improving the human condition in emergency, relief, rehabilitation, development).
 Liesbet Heyse, “Choosing the lesser evil: Understanding decision making in humanitarian Aid NGOs” (Hampshire, England: Ashgate Publishing Limited, 2006), 1-4.
 Bilateral is aid transferred from one country to another e.g., developed to developing country . Multilateral aid represents assistance from many countries that is distributed by the UN to (I)NGOs, private donors and implementing partners. .
 Larry Minear, The humanitarian enterprise: Dilemmas and discoveries, Kumarian Press, Bloomfield, Conn. 2002.
 These issues are explored in more detail later in this paper.
 Hakan Malmqvist, “Development Aid, Humanitarian Assistance, Emergency Relief”, Ministry for Foreign Aid, Sweden,
Monograph 46, February 2000.
From 2006-2010 nearly a quarter (24%) of humanitarian aid contributions were private/voluntary growing from 17% (2006) to 32% (2010). Global Humanitarian Assistance Report (2012): 25-27. In 1990 Overseas Development Assistance (ODA) accounted for 35% of total aid but now constitutes less than 15% as other sources have proliferated (private philanthropy, commerce, remittances from private households “Financing Development:Aid and Beyond,” (Robert Cornell (ed.)., OECD Development Centre Perspectives (2007): 12-15.
 Hakan Malmqvist, “Development Aid, Humanitarian Assistance, Emergency Relief,” Ministry for Foreign Aid Sweden, Monograph 46, (2000); 2-4.
 Input-financial, human, material; Output-products, services, relevant changes resulting from input; Outcome – achieved short and medium term effects; Impact – achieved long term effects. Short term focus = specific purpose(s); long term focus = specific sector.
 Rick McInnis-Ray, “Justice delayed for the wartime victims in the Democratic Republic of Congo,” Canadian Broadcasting Company, Toronto, Ontario, Canada Jul. 7, 2011.
 Peter Walker and Daniel Maxwell, Shaping the Humanitarian World, (Routledge: New York, NY, 2008): 97-117.
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 Michael Clemens, Steven Radelet, and Rikhil Ghavnani, “Counting chickens when they hatch: The short-term effect of aid on growth”, Centre for Global Development, Working Paper Number 44, July 2004.
 Amelia Branczik, “Humanitarian Aid and Development Assistance,” in Beyond Intractability. eds. Guy Burgess and Heidi Burgess. (Boulder, CO: Conflict Research Consortium, University of Colorado, 2004).
 Eli Malki, “A benchmarking model for measuring the efficiency of a humanitarian aid program: A case study of an international NGO,” Munich Personal RePEc Archive (MPRA): (2008): 11222, University of Munich Germany. http://ideas repec.org.
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 Frances Richardson, “Meeting the demand for skilled and experienced humanitarian workers,” Development in Practice 16, no. 3/4, (2006): 334-341.
 Culture = mores, traditions, customs, way of life, ethnicity. Values = principles, standards, morals, ethics. Beliefs = conviction, idea, certainty.
 Clark Gibson, Krister Andersson, Elinor Ostrom, and Sujai Shivakumar, The Samaritan’s Dilemma: The Political Economy of Development Aid (Oxford, UK: Oxford University Press, 2005.): 5-7, 127-130.
 Kersten Jauer, “Stuck in the ‘recovery gap’: The role of humanitarian aid in the Central African Republic,” Humanitarian Exchange Magazine 43, Humanitarian Practice Network, (2009): 28-30.
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 A phenomenon in which funding is no longer available even though it has been in the past. There are many causes for donor fatigue among which are overstretched budgets and/or frustration with what are perceived to be mismanaged programs and lack of progress.
 Musa Kana, “From brain drain to brain circulation”, Jos Journal of Medicine 4, no. 1, (2010): 8-10.
 The continuum model is the linear transition from E/R to R/D. The contiguum model’s flexibility allows rehabilitation and development measures to be implemented after the start of and/or alongside E/R activities.
 Margaret Buchanan-Smith and Paolo Fabbri, “Links Between Relief, Rehabilitation and Development in Tsunami Response”. A Review of the Debate,” Tsunami Evaluation Coalition Report, November 2005: 3-7.
 Paolo Dieci, “Linking Relief, Rehabilitation and Development: What Does It Mean Today?” VOICE Newsletter 4, December 2006.
 Margaret Buchanan-Smith and Simon Maxwell, “Linking Relief and Development: An Introduction and an Overview,” Institute of Development Studies Bulletin, Vol. 25:4 (1994): 8, 14-15.
Dr. Abby Stoddard, Center on International Cooperation; Adele Harmer, Humanitarian Policy Group, ODI; Katherine Haver, Center on International Cooperation; Dr. Dirk Salomons, The Praxis Group, Ltd. and Columbia University; Victoria Wheeler, Humanitarian Policy Group, ODI, Cluster Approach Evaluation Final, OCHA Evaluation and Studies Section (ESS), November 2007: 2, 45-46.
 Currently 137 countries and territories and 28 international organizations adhere to the Declaration. www.oecd.org/dac/effectiveness/parisdeclaration/members.
 Julia Streets, François Grunewald, Andrea Binder, Véeronique de Geoffroy, Domitille Kaufman, Susanna Kruger, Claudia Meier and Bonaventure Sokpoh. , Cluster Approach Evaluation 2 Synthesis Approach. Inter-agency Standing Committee (IASC), , Global Public Policy Institute, April (2010) 70-78.
 Adel Harmer and Deepayan Basu Ray, “Study on the Relevance and Applicability of the Paris Declaration on Aid Effectiveness in Humanitarian Aid”, Humanitarian Policy Group, Overseas Development Institute, London, March (2009): 7-11
 Currently 137 countries and territories and 28 international organizations adhere to the Declaration.
 International Aid Transparency Initiative, Good Humanitarian Donorship, Humanitarian Reform Initiative (2005), UNHCR Handbook for Emergencies, Sphere, ODI, ALNP, AIDA, Code of Conduct, Humanitarian Accountability Partnership (HAP), Good Humanitarian Donorship, International Aid Transparency Initiative (IATI), IASC. See Walker and Maxwell for a complete historical listing.
 Laurence Chandy and Geoffery Gertz, “Missing Poverty’s New Reality: There’s a Lot Less of It.” The Washington Post, (Washington, DC), Jan. 26, 2011.
 The Telegraph, “David Cameron arrives in Africa for trade mission,” Jul. 19, 2011.U.K.
 See Living Proof (http://livingproof.com) a website initiated in partnership with ONE by the Gates Foundation in 2010 to tell the stories of the incredible progress made in developing countries supported by donors.
 United Nations, “Eradicate Extreme Poverty and Hunger”, Goal 1, We Can End Poverty, Millennium Development Goals Report 2010, United Nations Summit 20-22 September, New York (2010): 4-5.This document reaffirms world leaders’ commitment to the MDGs and sets out a concrete action agenda for achieving the Goals by 2015.