The workers from a US aid group, on a recent mission to deliver food to displaced families from Fallujah, had to scramble for cover from air strikes targeting a fleeing Islamic State convoy.

“They called me and said, ‘They are killing us,’ ” says Jeremy Courtney, founder of the US group Preemptive Love, adding that the Iraqi and US air strikes were close enough to damage the relief vehicles and the hearing of one of the aid workers huddled in the sand.

The anti-IS security operation trapped the Preemptive Love staff and their partners from the Iraq Health Aid Organization in the desert overnight. It was a vivid illustration of the uncharted hazards of delivering aid in the world’s increasingly dangerous conflict zones that are leading to what some officials say is a crisis in the worldwide relief distribution system.

The privately funded Preemptive Love is among the smallest of only a handful of aid organizations operating in Anbar province, where the need for emergency aid far outpaces the ability of organizations able or willing to deliver it.

Three million Iraqis have had to flee their homes inside the country since the IS incursion in 2014, joining more than a million citizens already displaced and 250,000 Syrian refugees in Iraq. Although the humanitarian response in Iraq is one of the biggest aid efforts in the world, thousands of displaced families swelter under 110 degree heat, with little water and few toilets, in desert camps just an hour’s drive from Baghdad.

Relief officials say the lack of aid is symptomatic of an international aid system that not only is chronically underfunded but is ill-equipped to respond quickly or effectively in the conflict zones. They say many groups, including some of the largest, are unwilling to venture into the places they are needed most.

Outside UN headquarters in Baghdad’s fortified Green Zone is a plaque dedicated to the head of the UN mission in Iraq and 21 others killed when the headquarters were bombed in 2003. That attack and the killings and kidnappings of aid workers in other conflict zones since have helped create an environment so cautious that few UN aid staff, many of whom are Iraqi, are allowed in the field.

Restrictive security protocols

“Because it is an extremely high risk environment … we are working under very restrictive security protocols,” says Lise Grande, the UN Humanitarian coordinator in Iraq. “Those security protocols are designed to protect personnel, and it absolutely impacts on the way that we can get people in and out of operations.”

She says the UN, which uses nongovernmental organizations (NGOs) to implement its programs and deliver aid, has a difficult time finding international partners willing or able to operate outside of Iraq’s relatively safe Kurdistan region in the north of the country.

“It’s never been more difficult than it is now, and I don’t know what’s awaiting us tomorrow, but we need to do something,” says Carsten Hansen, regional director of the Norwegian Refugee Council, one of the few international groups delivering aid in Anbar province. ‘There are difficulties with the security issues, the political issues, on the ability to mobilize the manpower that’s needed for these massive operations.”

Mr. Hansen, touring a desolate makeshift camp near Amariyat al-Fallujah, just south of Fallujah, in late June, says the Norwegian organization has spent 18 months building the contacts needed with Iraqi government and security officials to obtain visas and approvals to work in Anbar. Even crossing the bridge to the Sunni Anbar province, an IS stronghold, requires special security permission.

Some NGOs pulled out of central Iraq and even the Kurdistan region when IS fighters swept across the country two summers ago, while others are just now beginning to look into operating there.

“It’s not like it’s an easy ride for us, either, but it’s a matter of building up relations and we have been doing that over a period of time,” says Hansen, who was visibly shocked by the lack of services and even sanitation at the camp. Aid officials are warning of the long-term effects of lack of immunization against diseases previously eradicated in the country and of a generation of children who have now missed more than two years of school.

A failure to respond to emergencies

In the sprawling camps full of traumatized women and children there is little evidence of coordination by the Iraqi government, which has primary responsibility for dealing with displaced Iraqis but has few funds, endemic corruption, and little capacity to deliver aid.

In addition, many in Iraq’s Shiite-led government accuse Fallujah residents of collaborating with IS, and it has not made humanitarian assistance a priority, despite pledges to reconcile with Iraq’s Sunni population.

Anger at the Iraqi government helped IS – and Al Qaeda before it – flourish in many Sunni areas. The overall lack of humanitarian assistance threatens to reignite that anger.

Doctors Without Borders (MSF), the most outspoken of the major aid organizations, has sharply criticized the international aid community for its failure to respond to global emergencies. It says while it recognizes the lack of funding, a greater constraint is an unwillingness to go where aid is most needed.

“In acute emergencies, when assistance is most needed, international staff of humanitarian agencies are rapidly evacuated or go into hibernation, and programs downgrade to skeleton staff or are suspended,” read a scathing MSF report in 2014 on programs that included aid to Syrian refugees in Jordan. “Some humanitarian agencies simply wait until the emergency passes to continue their usual, long-term programs.”

The report said the UN and its rampant bureaucracy and lack of internal coordination “was at the heart of the dysfunction” in each of the cases it reviewed. Some aid officials partnering with the UN also cite frequent staff changes and, in some countries, the disruption of staff leaving on vacation every two months.

Switch in focus to development, disasters

While Sandrine Tiller, a London-based co-author of the two-year-old MSF report, says little has changed since then, the United Nations High Commissioner for Refugees (UNHCR) says it has made inter-agency coordination a priority over that time. It says that unconnected to the MSF report, it has implemented measures to be able to better coordinate wide-ranging humanitarian operations.

“With every new emergency, every new wave of refugees, the pressure on the humanitarian response system builds,” says Ariane Rummery, a senior communications officer at the UNHCR in Geneva, in an email.

Ms. Tiller, meanwhile, says the humanitarian aid “sector is moving away to development issues and natural disaster response…. It’s harder to work in difficult places. The first is a whole security issue, and part of the security issue is that it’s hard to get people to go to places like Iraq.”

She says increased pressure and scrutiny from boards of directors of NGOs and donors, as well as a fear of lawsuits, have also limited the ability of organizations to respond effectively in conflict zones.

Last year, a Norwegian court found the Norwegian Refugee Council (NRC) guilty of gross negligence in a lawsuit launched by a former staff member kidnapped in Kenya in 2012, awarding him the equivalent of half a million dollars.

While the judgment has not stopped the NRC from deploying staff to conflict zones, security experts say it is likely to have a chilling effect, particularly on aid organizations in the United States, where such financial settlements could be much higher.

'Bureaucracy and risk aversion'

A recent book “Saving lives and Staying Alive,” by the MSF think tank CRASH, says the increased role of security advisers in humanitarian organizations has also led to aid workers being sequestered in fortified compounds far from the people they are meant to assist.

In Haiti, “as a direct result of the increased sway of the security discourse, humanitarian organizations have retreated behind the walls of fortified residences and offices and instituted ‘no-go times’ and ‘no-go’ zones for their staff,” finds the book.

The MSF 2014 study said it found that in countries where aid is most needed, including Jordan, the UN and international NGO response was “characterized by bureaucracy and risk aversion,” with aid concentrated in capital cities or in the biggest camps, with few programs for those in greater need who are more difficult to help.

“There’s some risk aversion that happens quite simply because of the demand for results,” says Tiller. “It’s much harder to show results when you’re working with highly mobile populations.”

MSF, which says 75 of the hospitals it supports in conflict zones were bombed last year, boycotted this year’s World Humanitarian Summit in Istanbul in June, saying the summit focused on development issues and would not address the weakness in humanitarian action and emergency response.

Many of the governments attending the summit were also involved in military operations in the countries where they have humanitarian assistance programs.

“I think one of the perplexing things and one of the frustrating things is why the international community is investing so much on the military side in the battle to defeat DAISH [Islamic State] and it is not resourcing the humanitarian side.… There needs to be a rebalance,” says the UN’s Ms. Grande, who is American. “It doesn’t make sense to invest in the military operation and not invest in the people … victimized” by IS.

Girding for Mosul

While the United States is the biggest donor to chronically underfunded UN humanitarian agencies, other countries have called on it to dramatically increase the contribution to reflect its role in the war in Iraq and the subsequent fighting that has displaced millions of Iraqis.

Grande says the humanitarian assistance plan for Mosul, the IS stronghold in northern Iraq, could be the biggest humanitarian effort in the world this year. Depending on the severity of fighting and length of the battle for the city, planners are expected between 300,000 and one million people to be displaced by the fighting.

Mr. Courtney, the founder of Preemptive Love, says the group has been learning as it goes along about delivering emergency aid. The organization started working a decade ago in Iraq, bringing in teams of heart surgeons to operate on children and training Iraqi doctors and surgical staff.

He says when they saw the need for emergency response two years ago when IS forces invaded, they switched gears.

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When the aid delivery derailed by the air strikes on the IS convoy couldn’t get to its original destination after the roads were closed, he says the team leader insisted on carrying on with the mission to another camp.

“We are organized around a principle of trying to carefully, intelligently, but ultimately daringly if necessary reach out … to help those people who don’t have any other options,” he says. “When that is your organizing principle, it affects how you look at conflict, how you look at loss, how you hire and recruit.”