Conflicts in the Middle East, especially the Syrian conflict, are stretching the humanitarian community more than ever before. There are almost 60 million displaced people around the world, the largest exodus in recorded history; nearly a quarter of whom are from the Middle East, with 20% from the Syrian conflict alone. As the region generating the most displacement and the host to the largest number of displaced persons, the Middle East presents unique challenges for the international community, including donors like us at USAID.

The U.S. government is the largest donor to the international humanitarian effort to relieve those impacted by the Syrian conflict, providing more than $4 billion in humanitarian assistance since the beginning of the crisis, in addition to development funding put towards Syria’s neighbors. We are also deeply engaged in the crises in Iraq and Yemen. Providing for the health care needs of people trapped in conflict zones, as well as refugees and host communities, is a critical priority for us at USAID. However, in the health sector as in other sectors, we struggle to meet the enormous needs of those caught in the crossfire, especially inside Syria—being the largest and most complex humanitarian emergency of our time.

Below, I outline five main challenges USAID faces, and highlight a few ways we are working with donors and partners to find creative and durable solutions to the region’s health care and broader needs.

  1. 1. Improving Implementation

The sheer scale and brutality of conflicts in the region make it extremely difficult to reach those in need. Lack of secure access is always an obstacle for both aid providers and recipients. In Syria, the regime and other extremists have blocked the delivery of surgical and other medical supplies and have targeted medical facilities. According to Physicians for Human Rights, there have been 256 attacks on 194 medical facilities over the past four years, killing at least 624 healthcare workers. As the conflict drags on, Syria’s health care system has been decimated; average life expectancy has dropped by nearly 20 years over the past five years.

We struggle to provide primary health care, while also meeting the specialized needs of those injured by violence. Our response must be agile, as we are often operating in four different environments: government-held areas, areas held by opposition forces, refugee and displaced persons camps, and host communities in which refugees are living. Our access is particularly constrained in areas held by government or opposition forces that do not respect humanitarian principles. Reaching people in areas held by ISIS (also known as the Islamic State) is especially difficult.

At great personal risk, our partners do everything possible to reach those in need across borders and across conflict lines. Local actors keep our partners abreast of fast-moving developments and monitor health conditions on the ground. For instance, they let us know if in a particular month they need us to provide them with more surgical supplies because fighting is on the rise, or with medicines for chronic conditions, or with vaccines and antibiotics to treat and ward off infections.

Our NGO partners in Syria have also developed operating principles jointly with the United Nations that explain, in plain language, how humanitarian principles work in practice in order to clarify and negotiate access with all parties. U.N. Security Council Resolutions 2191 and 2165, which authorize the U.N. to cross border and conflict lines without approval by the Syrian regime, have strengthened cooperation between the U.N. and NGOs that were already operating across border and conflict lines. The donor, U.N., and NGO communities must continue to identify other operational and policy solutions to reach those in need.

  1. 2. Strengthening Coordination

Given the magnitude of the crises in the region, coordination between donors, governments, nongovernmental actors, and within the U.N. system, is critically important. In the Syria crisis, the humanitarian community has undertaken several steps to improve coordination among the myriad actors providing assistance. In 2014, the U.N. adopted the Whole of Syria approach, which put the various U.N. operations dealing with this conflict under a single framework in order to increase the efficiency, accountability, and reach of humanitarian programming. This approach has greatly improved coordination, providing a staffing and operational structure through which our U.N. and NGO partners can coordinate assistance for health and other sectors across Syria, and in neighboring countries.

  1. 3. Increasing Funding

Funding is most certainly one of our most pressing challenges across the Middle East and globally. Although donors are giving more than ever to face these challenges, contributions are outpaced by the rate at which needs are growing. U.N. humanitarian appeals globally ballooned from $3 billion in 2004, to $20 billion this year—about half of which is for Syria and Iraq alone.

In order to meet growing health and other urgent needs in the region, we must determine how to both use our limited resources more efficiently and increase the pool of available funds. Working jointly with the State Department and other major donors, we have carried out extensive outreach to nontraditional donors; it has been heartening to see more Middle Eastern actors, such as Kuwait, stepping up to provide humanitarian assistance. We must continue to look to our Middle Eastern partners as vital stakeholders in the future of their own region.

We must also explore opportunities for engaging the private sector. As a region with one of the largest young populations in the world, the Middle East faces many challenges, but also enormous promise. We must seek ways to incentivize private sector partnerships that can promote greater stability, economic opportunity, and well-being in the region.

  1. 4. Ensuring Oversight

As budgets grow tighter, we must make sure each dollar goes to those most in need. Yet, in extremely insecure environments like Syria and Yemen, we often do not have staff on the ground to monitor and provide oversight of programs directly. Our partners have, however, found innovative ways to tightly monitor our assistance in conflict zones. In places like Syria, where cell phones are ubiquitous, partners use GPS and other technology to track the delivery of assistance from its point of origin to when it reaches its intended beneficiaries. We have also worked with partners to target our assistance toward those who are most vulnerable. As a result of the innovation and dedication of our partners, and with the help of technology, we actually have very effective and accurate systems for monitoring and overseeing assistance.

  1. 5. Moving from Relief to Development

The ongoing conflict in Syria and Iraq has radically reshaped the demographics of the Middle East. Turkey now hosts more refugees than any other country in the world. Many Jordanian and Lebanese towns along the Syrian border have doubled or tripled in size due to the influx of Syrian refugees. With the forced displacements lasting an average of 17 years, globally, it is reasonable to assume that many of these refugees are unlikely to return home for years, if not decades.

In light of these realities, we are identifying strategies to build the capacity of host countries to cope with the long-term needs of refugees and the communities in which they live. In our Syria response, we are pivoting our assistance towards refugee-receiving host communities to expand the capacity of their health systems to meet growing demands and mitigate rising tensions over stretched resources and facilities. We are currently the largest donor to Jordan’s health sector, providing more than $445 million in the past five years. We have expanded access to care at 20 out of 30 Jordanian public hospitals; more than a quarter of all deliveries Jordan-wide now take place in public hospitals largely renovated by our partners. Due to these efforts, maternal, infant, and under-five mortality rates have decreased throughout Jordan. Moving forward, we are integrating population dynamics into the planning and strategic design of programs across the Middle East, and taking into account the unique needs of refugees, especially women and children.

We remain committed to thinking creatively and working with partners to improve the well-being of the more than 15 million people displaced by conflict in the Middle East, and the communities they live in. But we know that their needs will continue to grow beyond what we can provide. Next year’s World Humanitarian Summit planned for May in Istanbul, provides an important venue to address critical funding shortfalls, foster greater collaboration, and move towards a more effective humanitarian system that can meet the long-term challenges ahead. Paving a new way forward will be critical to ensure a more peaceful and prosperous future for the Middle East.