Declining humanitarian funding and health security threats: insights from Rohingya refugees and host communities in Ukhiya and Teknaf, Bangladesh

The Rohingya people are frequently acknowledged as one of the most persecuted cohorts worldwide, enduring systematic human rights violations and prolonged marginalization (Faye 2021). The Rohingya refugee crisis escalated significantly in 2017, resulting in the displacement of approximately 960,000 Rohingya individuals from Myanmar to the coastal areas of Ukhiya and Teknaf in Cox's Bazar, Bangladesh (Albert & Maizland 2020; Rohingya Refugee Response 2023). This unprecedented influx placed significant strain on local infrastructure and introduced socioeconomic challenges, including competition for resources between refugees and host communities. In response, international humanitarian aid surged, initially focusing on water, sanitation, and hygiene (WASH), nutrition, and healthcare services (Azad 2024).

As the crisis persisted, humanitarian assistance diminished, adversely affecting critical services, mainly food and health security. In the Rohingya refugee camp, limited healthcare services and inadequate WASH provisions continue to pose challenges. The COVID-19 pandemic further exacerbated vulnerabilities in both refugee camps and neighboring communities, depleting resources and intensifying challenges. Since 2020, fear of COVID-19 and financial constraints have become key barriers to healthcare access. Understanding the factors influencing healthcare-seeking behavior is essential for improving preparedness and service delivery at the primary and secondary levels (Altare et al. 2024). Humanitarian organizations have reported a significant decline in funding, complicating efforts to meet health needs, maintain essential services, and control disease outbreaks.

The Inter-Sector Coordination Group (ISCG) (2024) in Cox's Bazar reported a consistent decline in financial support for Rohingya refugees and host communities since 2020, which is primarily attributable to shifting global priorities and donor fatigue. The funding requests, received amounts, and deficits over time (Table 1) reveal significant shortfalls, particularly in 2020 during the COVID-19 pandemic and again in 2023 (ISCG 2024). These deficits underscore the urgent need for sustainable financing to address ongoing crises and alleviate the pressure on both refugees and host communities.

The Rohingya Humanitarian Crisis Joint Response Plan (JRP) (2023) provides detailed analyses of service provision and financial tracking. For instance, the health sector required $97.3 million, yet received only $48.4 million, representing 49.7% of the needed funds. Similarly, the nutrition sector received $19.4 million out of $40 million requested (48.3%), while the WASH sector secured $37.4 million out of $78.8 million (42%) (OCHA Financial Tracking Service 2023). This funding shortfall has led to deteriorating health security, a surge in infectious diseases, and increased malnutrition rates among refugee and host populations. Contributing factors include camp overcrowding, limited access to clean water, and shortage of healthcare personnel (Nadia 2021).

In response, Bangladesh, in collaboration with the United Nations, non-governmental organizations (NGOs), and international entities, has undertaken efforts to address these challenges by establishing facilities such as the Bhasan Char and allocating substantial financial resources (Palma 2021; Korobi 2023). However, the economic pressures faced by the host nation, aggravated by global conflicts and inflation, have presented significant obstacles to the sustainability of humanitarian initiatives (Rahman 2023).

Following the 2016 World Humanitarian Summit, localization emerged as a pivotal focus within humanitarian relief efforts, underscoring the need for increased involvement of local and national entities that have historically been marginalized within a global North-centric paradigm (Brun & Horst 2023). Nevertheless, financial limitations have substantially impeded the health sector's capacity to address the Rohingya crisis, mirroring broader global issues. For instance, in Colombia, Venezuelan migrants experience restricted access to primary healthcare, while in Brazil, the overwhelming demand for healthcare services from Venezuelan migrants has resulted in shortages of medications and medical supplies. These challenges have culminated in deteriorating maternal and neonatal health outcomes, alongside rising rates of infectious diseases (Doocy et al. 2019).

As observed in both Colombian and Brazilian contexts, inadequate sanitation and clean water infrastructure further exacerbate these challenges (Roberts & Kelman 2022). Globally, insufficient sanitation and waste management constitute primary drivers of health issues, particularly within densely populated refugee camps in the global South. Research focusing on Rohingya camps has illuminated similar sanitation and waste management challenges, including littering, open defecation, and obstructed drainage systems, which contribute to flooding and the contamination of living environments (Uddin et al. 2022).

The extensive settlement of Rohingya refugees has also precipitated environmental degradation, encompassing deforestation, biodiversity loss, and increased pressure on water resources (Sadat al Sajib et al. 2022). Environmental changes can exacerbate respiratory infections in overcrowded, resource-limited refugee camps (Paolo 2023). This strain on natural resources has heightened competition between refugees and host communities, exacerbating social tensions (Islam et al. 2022).

Moreover, reductions in humanitarian assistance have exerted additional pressure on healthcare systems, restricting access to quality medical treatments. Early in the response, minimum service standards for primary healthcare and community health outreach were established, standardizing services and strengthening the health workforce (Jeffries et al. 2021). As beneficiary satisfaction with service quality was already low, highlighting the need for improvement. Standardizing primary healthcare and community outreach remains crucial for strengthening services (Masud et al. 2017). In Bangladesh, the health sector grapples with financial constraints and challenges in service delivery. Conversely, in the United States, Burmese and Karen refugees face cultural and linguistic barriers that complicate their access to healthcare (Yalim et al. 2019). In numerous low- and middle-income countries, particularly in sub-Saharan Africa, accommodating large populations of refugees and internally displaced persons has further strained already limited public healthcare resources (Tafesse et al. 2024). These challenges underscore the critical link between adequate support and the preservation of the dignity of displaced populations.

Considering these challenges, this study aims to assess how dwindling humanitarian funding affects the health security of both Rohingya refugees and nearby host communities in Cox's Bazar. Specifically, it examines three core domains:

• (1) Access to nutrition – Evaluating malnutrition trends and the impacts of ration cuts, particularly among vulnerable groups such as women and children.

• (2) WASH services – Investigating the adequacy of water quality and quantity, sanitation infrastructure, and hygiene promotion activities in the camps and adjacent areas.

• (3) Healthcare provision – Analyzing the capacity of existing health facilities to manage infectious disease outbreaks and chronic conditions under constrained budgets.

Employing both qualitative and quantitative methods, including household surveys (HHSs), focus group discussions (FGDs), key informant interviews (KIIs), and sector-specific data, this research offers evidence-based insights into how funding shortfalls jeopardize health outcomes and overall well-being. It also highlights the novel contribution of a multi-dimensional approach, simultaneously examining nutrition, WASH, and healthcare in a protracted refugee setting. The findings aim to inform donors, policymakers, and humanitarian organizations, emphasizing integrated solutions that can strengthen resilience and improve long-term health prospects for displaced and host populations alike.

The research methodology employed in this study demonstrates a comprehensive and multifaceted approach to assessing health security. Using a mixed-methods design, the researchers collected qualitative and quantitative data, providing a more holistic understanding of the subject matter. The primary data collection methods included FGDs, KIIs, and HHSs, which allowed for the capture of diverse perspectives and experiences (Supplementary material). This approach was further enhanced by the integration of sectoral reports, offering broader contextual insights and a more nuanced understanding of the complex issues faced by the affected populations. This study specifically focused on access to nutrition, WASH services, and healthcare in Ukhiya and Teknaf Upazilas, covering camps in the Palong Khali and Rajapalong areas. The data collection period spanned from December 2023 to May 2024, with sectoral reports up to October 2024. This comprehensive methodology not only provides a rich dataset but also highlights the importance of developing inclusive strategies to address the identified challenges in health security. The research was conducted in the Ukhiya and Teknaf Upazilas of Cox's Bazar district, situated in southeastern Bangladesh. This region is notable for hosting one of the largest concentrations of Rohingya refugees globally, with approximately 1 million individuals who have sought asylum from persecution in Myanmar. As of 2023, Ukhiya has an estimated population of approximately 242,782 inhabitants, while Teknaf has around 301,679 residents. The influx of Rohingya refugees has significantly increased the population density in these Upazilas, resulting in heightened competition for limited resources and services.

Geographically, Ukhiya and Teknaf are characterized by hilly terrain and forested areas that have been adversely affected by the extensive settlement of refugees. The region's proximity to the Bay of Bengal renders it vulnerable to natural disasters such as cyclones and flooding, complicating ongoing humanitarian efforts. The United Nations, multiple international NGOs, local organizations, and government bodies are operational in the area, providing essential services such as nutritional support, healthcare, and WASH promotion services.

This study focused specifically on unions adjacent to refugee camps such as Hnila in Teknaf Upazila and Palongkhali and Rajapalong in Ukhiya. Within the host community, emphasis was placed on areas with significant refugee camps, specifically camps 1E, 2E, and 11. These locations were selected due to their substantial refugee populations; approximately 83% of refugees reside in Ukhiya Upazila, with these selected camps representing approximately 13% of households. In the camp setting, all agencies respond according to sectoral strategies to ensure that participants represent the overall camp population. This targeted approach captured perspectives from the highest-density populations while acknowledging the overarching humanitarian context in Cox's Bazar.

A mixed-methods approach was adopted to capture both qualitative and quantitative perspectives on health security within refugee camps and host communities. Three primary sectors were examined:

• Nutrition (including malnutrition trends and food ration dynamics),

• WASH (water access, sanitation infrastructure, and hygiene practices), and

• Healthcare (service availability, disease prevalence, and overall healthcare access).

Qualitative methods included FGDs and KIIs. A total of 8 FGDs were held: 5 in Rohingya camps (40 participants) and 3 in host communities (30 participants). These discussions explored perceptions of nutrition, WASH services, and healthcare challenges. Ten KIIs were conducted with local elected officials, organization's sector leads, healthcare providers, NGO staff, and community leaders to gain deeper insights into service delivery issues amid funding constraints.

Quantitative methods encompassed HHSs and sectoral reports. Structured HHSs were administered to 104 respondents (52 from host communities and 52 from refugee camps) to assess satisfaction levels and perceptions of service provision. While the sample size was limited, it was deemed sufficient to gauge general attitudes and highlight major gaps. Data from sector-specific monitoring (e.g., food rations, nutritional status, WASH infrastructure coverage, healthcare usage rates) were integrated to corroborate and contextualize the primary data. Additionally, quantitative data were collected regarding changes in service provision. This included detailed information on specific reductions in food rations provided to refugees over time. Furthermore, information on the number of beneficiaries served by WASH facilities, such as the ratio of people per latrine or water point, was gathered to assess how funding cuts would impact service availability. Lastly, information was gathered on healthcare access, particularly access to services, quality of services, and the most prevalent health-related diseases from the sectoral reports to provide an overview and identify current gaps. These data are crucial for assessing the need to continue humanitarian support.

All FGD and KII notes were transcribed and analyzed thematically to identify recurring patterns and main topics. All data were anonymized during analysis and reporting to protect participant identities. HHS data were entered into a spreadsheet (or relevant statistical software) for descriptive analysis (frequencies, percentages). Findings from primary data were then cross-referenced with secondary sources (nutrition, health, and WASH sector reports) to form a comprehensive assessment of service gaps and challenges.

This study highlights several key points related to the current states of health security and the impact of funding restrictions, on nutrition, WASH, and healthcare, for both Rohingya refugees and the surrounding host communities in Cox's Bazar.

Our findings indicate that persistent reductions in humanitarian funding are closely linked with deteriorating health conditions. Declining financial support affects multiple, interconnected sectors, including nutrition, WASH, and healthcare, each of which plays a crucial role in protecting public health and overall well-being. Inadequate funding compromises the quality and reach of services, intensifying vulnerabilities and potentially leading to long-term adverse health outcomes.

The study examined the status of nutrition-specific and nutrition-sensitive interventions and their impact on malnutrition in both refugee camps and surrounding communities. In these settings, insufficient resources impede the comprehensive implementation of such measures. Nevertheless, prioritizing these interventions remains crucial for addressing malnutrition. KIIs indicate a focus on referring cases for specialized treatments. However, achieving desired nutritional outcomes proves challenging without collaborative efforts. Nutrition sector data reveals that global acute malnutrition has increased to 15.1%, reaching its highest level since the 2017 influx (UNHCR Bangladesh 2023), primarily due to the limited availability of nutritious food. Financial constraints exacerbate this situation, intensifying malnutrition and hindering effective responses, while current coping strategies prove inadequate.

Médecins Sans Frontières (MSF) (2023) also reports that a significant proportion of pregnant women receiving care at their facilities exhibit signs of malnutrition, presenting substantial health risks for both mothers and neonates.

It is imperative to prioritize nutrition programs that implement measures to prevent acute malnutrition; however, due to reductions in funding, these programs have been scaled back, impeding the maintenance of nutrition standards in specific areas of the camp and host communities. Children under five, pregnant women, and breastfeeding mothers are particularly vulnerable (MSF 2023). As noted in KIIs, regular monitoring and treatment assessments are essential within nutrition programs, but funding shortages have compelled organizations to reduce staff numbers while increasing their responsibilities. If these funding declining trends persist, organizations may encounter difficulties in implementing nutrition programs according to standard requirements. Presently, addressing malnutrition in children, pregnant women, and lactating mothers within necessary timeframes remains a significant challenge, contributing to elevated rates of morbidity and mortality.

Investment in WASH is one of the most efficacious public health interventions; however, funding for WASH in Cox's Bazar has decreased significantly over the past year. According to WASH (2024) sector data analysis, the funding for WASH efforts in Cox's Bazar has substantially declined over the past year, indicating a downward trend in both requested and received funding. The stabilization of budgeting between $55 and $60 million suggests that future responses may necessitate operation within a more constrained financial environment.

A persistent disparity exists between the requirements of the WASH sector and the funding obtained; however, this gap has diminished, potentially because of decreased overall funding requests. The WASH sector is undergoing a rationalization process and adapting to this declining trend; nonetheless, there is an urgent need for enhanced funding to address escalating demands in the area.

Access to WASH services has become a significant challenge for Rohingya individuals in some sub-sectors, particularly given soap shortages that affect families with newborns and children. One Rohingya woman described her situation: ‘I have a baby and need to wash clothes frequently. Residing in a densely populated area means that our children often play in muddy fields or roads, and their clothes become soiled daily. Due to the scarcity of clothing, we must wash it regularly, so a single bar of laundry soap is insufficient’. This situation underscores the difficulties families encounter in maintaining hygiene under these conditions.

Additionally, ongoing cases of acute diarrhea within the Rohingya camps have been reported (WASH Sector, Cox's Bazar 2024). Acute diarrhea cases have been increasing since 2023 in Teknaf and since 2022 in Ukhiya Upazila. According to sectoral data (2024), cases are at their highest level in 2024 since 2017. In 2023 and 2024, continued cases were observed, with 2024 exhibiting fluctuating but persistent activity (up to approximately 10 cases observed in some weeks) (WASH 2024). This pattern indicates cyclical eruptions with varying intensity, and the trends in 2024 underscore the necessity for enhanced monitoring and interventions.

Although there has been an increasing trend in acute watery diarrhea (AWD) prevalence since 2023 in both the Ukhiya and Teknaf areas (WASH Sector, Cox's Bazar, 2024) which is not exclusively attributable to WASH issues, there has is also been a gap in oral cholera vaccination (OCV) in recent years; improving these services could contribute to the prevention of such illnesses. MSF (2023) has also documented exacerbation of dermatological conditions during certain periods within the camps. Sustained funding is essential for managing epidemiological concerns.

As per the WASH Sector Report (2024), dengue cases also demonstrate an upward trend since 2022. To mitigate this increasing trajectory, intensive awareness interventions are essential, necessitating adequate staffing and sustained funding. However, a continued decline in financial resources would severely compromise WASH intervention, leading to a potential threat to health security initiatives designed to address and effectively control dengue.

KIIs reveal that reduced funding has created significant challenges in maintaining adequate water and sanitation facilities. There is an emerging issue of missing components such as head pumps (tube wells), and handwashing device. Additionally, the age structure of the WASH facilities requires reconstruction, but funding limitations pose a threat to addressing these needs. An agency representative stated, ‘It is challenging to build new WASH facilities due to funding constraints. Many existing structures were established after the influx; some now need reconstruction. However, the available financing is decreasing, creating challenges’. Reduced funding also impedes organizations from promptly addressing repairs and maintenance, further compromising service quality. The situation has also affected host communities. Numerous agencies are reducing their budgets, leading to reductions in staff and volunteers as well as limited capacity to procure necessary WASH materials. This impacts regular support for host communities. Furthermore, some organizations have reallocated 20–30% of their budget intended for host communities toward urgent needs in Rohingya camps, exacerbating tensions.

A significant challenge will be faced due to water access issues. According to the United Nations Development Programme (UNDP, Bangladesh 2019), the groundwater levels have decreased by approximately 5–9 m due to over-extraction. With the host community asserting that their shallow layer is declining significantly, they are experiencing issues related to safe water access, which they did not face before the influx. This situation potentially leads to conflict over this depleting resource between the camp and host community. Financial constraints have also delayed essential infrastructure development, such as surface water treatment plants necessary for addressing water supply crises. Moreover, disaster-response stockpiles are at risk of depletion due to ongoing budget reductions. According to a study by the Institute of Water Modelling (IWM) (2023), only 53% of the camp's water network meets sectorial standards, while 47% fails to maintain the required chlorine ratio, potentially one of the major causes can be staff shortages to do proper monitoring.

According to KIIs, funding cuts pose a threat to environmental sustainability particularly concerning fecal sludge management and solid waste disposal. However, the WASH sector has achieved notable success in preventing cholera epidemics by addressing key requirements such as constructing fecal sludge treatment facilities and establishing water networks.

Despite these challenges, efforts have been made to maintain WASH standards. WASH Sector (2024) also reported that data from a fecal sludge treatment laboratory indicated that compliance with chemical oxygen demand (COD) standards improved between early 2022 and early 2023. The percentage of fecal sludge treatment plants (FSTPs) meeting acceptable COD standards decreased from 65% in 2022 to 21% in 2024 (COD standard 18% in January–April 2022, 65% in January–April 2023, and 21% in January to May 2024) (WASH Sector, Cox's Bazar 2024). Additionally, the number of FSTPs reduced from 205 (in 2022) to 167 (in 2024) (WASH Sector, Cox's Bazar 2024). Furthermore, in 15 of the 33 camps, the number of individuals per functional latrine does not meet the standard ratios. While the average usage across camps is 20 people per latrine, these 15 camps exhibit a ratio of 1:26, indicating that one latrine is utilized by 26 people. This represents a substantial deviation from the sphere standards for recommended latrine use (1:20).

According to the WASH Sector monitoring overview (2024), the average volume of domestic water collection per person per day demonstrates a concerning decline, decreasing from 27 L in 2021 to 23 L in 2024. Regarding equitable water distribution, the WASH sector's monitoring overview indicates that 18% of individuals still have access to less than 20 L of water per person daily, which is below the recommended minimum. In protracted situations, the standard necessitates at least 20 L per person per day to meet basic needs (WASH Sector, Cox's Bazar 2024). In this situation, continued funding is essential to prevent any deviation in the response.

In the host community, data from the district WASH Sector (2024) situation assessment indicates that 77% of individuals have personal latrines; however, 25% of these are classified as unimproved, revealing a 23% gap between latrine ownership and quality. This disparity, coupled with the prevalence of substandard facilities, raises significant concerns about fecal contamination. Similarly, while 62% of the population has adequate access to water, 38% face limited availability, and 15% continue to depend on unimproved water sources, further increasing associated risks. Adding to these challenges, declining funding for the host community exacerbates tensions and conflicts surrounding the Rohingya refugee response (DPHE-UNICEF 2024).

The current state of WASH services and accessibility underscores the critical need for sustained funding to address public health risks. Any reduction in financial support compromises the continuity and quality of WASH services in both the camps and the host community.

KII participants emphasized that despite challenges in maintaining adequate healthcare within the camps, medical personnel and institutions are attempting to provide services; however, increasing essential costs in Bangladesh, particularly medical expenses, have made it progressively challenging for individuals requiring treatment outside the camp. This concern is especially pertinent for serious conditions necessitating specialized care unavailable in camp clinics.

The KIIs also revealed that health posts, primary health centers, and field hospitals dependent on humanitarian funding have been significantly impacted by financial constraints. Many health posts have ceased operations. As per health sector data in 2018, the health sector encompassed 126 partners and 216 service facilities, including health posts and primary health centers. By 2024, these numbers had decreased to 56 partners and 100 health service facilities, creating gaps in equitable access to healthcare and impeding high-quality medical service maintenance. Moreover, primary health centers and hospitals at district and Upazila levels have become overburdened due to increased referral cases from camps, exacerbating existing strains on healthcare systems.

The maternal mortality rate is reported to be higher than ever, and access to health service strain has led to increased dissatisfaction within the host community, as more residents are competing with refugees for limited healthcare resources. A local woman from Rajapalong shared her experience, highlighting the growing frustration within the host community: ‘Previously, accessing basic healthcare was relatively straightforward for us, and we did not encounter Rohingya patients. However, our clinic is currently inundated with refugees in need of assistance. Medical professionals are working diligently to treat as many individuals as possible. We find ourselves waiting in crowded conditions, reminiscing about less complex times’.

The health sector gap analysis (Health Sector, Cox's Bazar 2024) reveals inequalities in healthcare accessibility. The findings show that 22% of respondents encountered obstacles when seeking medical services (Health Sector, Cox's Bazar 2024). Among those facing difficulties, the most significant impediment was extended waiting periods. Other notable barriers included insufficient available services, transportation issues, language obstacles, service costs, discrimination, and apprehension toward authorities. The analysis emphasizes that the primary challenges are rooted in structural and logistical factors, particularly wait times, service availability, and transportation concerns.

The health sector also reported that 23% experienced regular shortages of medicine at the health facility (Health Sector, Cox's Bazar 2024). While the majority do not encounter issues with drug availability, the 23% deficit indicates a significant challenge that could impact healthcare delivery in specific facilities or regions (Health Sector, Cox's Bazar 2024).

The quantitative and qualitative data together paint a concerning picture: declining humanitarian funding is not only eroding the quality of essential services but also exacerbating health disparities between refugee and host populations. The interplay between reduced nutrition, compromised WASH services, and strained healthcare systems forms a vicious cycle that jeopardizes the overall health security of the region.

The study's findings highlight the significant health security challenges faced by Rohingya refugees and host communities in Cox's Bazar, primarily because of the decreasing availability of humanitarian aid. The influx of refugees since 2017 has placed substantial strain on the local infrastructure and resources. Initially, international donors supported humanitarian efforts focused on essential services, such as nutrition, WASH, and healthcare. However, as the crisis continued, donor fatigue and changing global priorities led to substantial funding reductions, severely impacting critical services.

Resource dependence theory (RDT) and social capital theory provide valuable frameworks for understanding these dynamics and proposing targeted policy interventions. RDT suggests that organizations rely heavily on external resources, and reductions in these resources significantly hinder operational capacity (Loasby 1979). This underscores the need for policies that prioritize diversified and sustainable funding streams to reduce dependence on a limited donor base.

Reduction in humanitarian aid has constrained the delivery of nutrition and WASH services, leading to deteriorating health outcomes. Global acute malnutrition (15.1%) and stunting growth rates (41.2%) now exceed emergency thresholds. Declining WASH service standards have contributed to the spread of diseases such as acute diarrhea and dengue. Additionally, reduced food rations have left many families struggling, with the proportion of households maintaining sufficient food consumption decreasing from 56 to 22% (Nutrition Sector 2023).

Social capital theory illustrates how weakened social networks within refugee and host communities exacerbate these challenges (Putnam 2000). The lack of a cohesive community advocacy for resources has intensified the strain on essential services such as WASH, which are crucial for preventing diseases such as Acute Watery Diarrhea (AWD) and cholera. The interplay between resource dependence and social capital reveals a complex dynamic where reduced external support not only directly affects service provision, but also weakens community capacity to advocate for and optimize resource use. Addressing these issues requires an integrated policy approach that combines material resource allocation and efforts to rebuild social cohesion. Strategic resource management policies are critical to ensuring long-term success and stability.

Findings related to WASH services indicate a significant decline in access to essential items such as soap, safe water, and sanitation facilities. Gaps in water and latrine access per person have increased the vulnerability to diseases such as diarrhea and dengue (WASH Sector, Cox's Bazar 2024). Despite efforts to maintain service standards through fecal sludge treatment facilities, financial constraints have hindered the sustainability of these interventions. Policymakers must explore innovative solutions, such as integrating refugees and host populations into collaborative water management programs, incentivizing technological advancements in sanitation, or scaling community-led sanitation initiatives (Ripoll 2017). Additionally, policies encouraging water conservation, surface water treatment, the controlled installation of tube wells, and sustainable water network management can enhance functionality and foster equitable resource distribution.

Groundwater depletion in Ukhiya and Teknaf adds another critical dimension to this crisis. Overreliance on natural resources has resulted in significant depletion, consistent with the tragedy of the commons theory, which elucidates how shared resources are over-exploited when individual users prioritize personal benefits over collective sustainability. The documented drop in groundwater levels underscores unsustainable extraction practices that exacerbate tensions between refugees and host communities. Policymakers must adopt participatory and sustainable approaches such as Integrated Water Resource Management (IWRM), restricting unregulated tube well installations, and promoting shared water infrastructure. These policies should be complemented by awareness campaigns to encourage water conservation and equitable resource allocation, mitigate tension, and foster long-term sustainability.

Healthcare access has also been severely impacted, with funding cuts resulting in the closure of numerous health posts and increasing strain on the local healthcare systems. This has widened inequities in access to medical services, with 22% of respondents reporting gaps in healthcare access and 23% identifying shortages in medicine supply. Moreover, host communities increasingly perceive that their healthcare needs are overshadowed by those of refugees, intensifying tensions over resource allocation. To address these disparities, policymakers should prioritize the establishment of integrated healthcare systems that serve both communities equitably. These could include mobile health clinics, subsidized medicine distribution programs, and investments in local healthcare infrastructure to reduce dependency on external funding.

The challenges observed in Cox's Bazar exemplify similar crises globally. Venezuelan migrants in Colombia and Brazil, for instance, experience limited access to primary healthcare due to resource constraints. This situation is analogous to Cox's Bazar, where reduced funding has resulted in healthcare facility closures and increased competition for limited resources. Systems theory concepts, emphasizing the interconnectedness of service systems, suggest that disruptions in one sector, such as healthcare, can have cascading effects on others, including WASH and nutrition. Comparative analysis indicates that addressing these systemic vulnerabilities necessitates integrated, cross-sectoral strategies.

To address these challenges effectively, a multifaceted and theory-informed approach is necessary.

• • Enhanced funding mechanisms:

• • – Establish innovative funding models, such as public–private partnerships and community-based financing, to ensure consistent resource flows; align these efforts with RDT principles to mitigate overreliance on single-donor sources.

  • – Diversify funding sources by engaging non-traditional donors, philanthropic entities, and regional organizations.

• • Integrated health and WASH programs:

• • – Develop holistic programs that simultaneously address nutrition, WASH, and healthcare. Incorporate hygiene education into nutrition-related healthcare outreach initiatives to amplify impact, reflecting social cognitive theory insights on behavioral change.

  • – Promote sustainable WASH technologies, such as solar-powered water pumps and eco-friendly waste management systems, to reduce dependency on external aid.

• • Empowering local stakeholders:

• • – Enhance the capacity of local NGOs and community organizations, leveraging social capital theory principles to strengthen trust, collaboration, and advocacy within communities.

  • – Facilitate skill development programs for community members to enable active participation in maintaining WASH and healthcare infrastructure.

• • Conflict mitigation and social cohesion:

• • – Implement targeted initiatives to address resource-based tensions between refugees and host communities, such as shared water infrastructure and joint reforestation projects. Draw on conflict transformation theory to transform resource competition into cooperation opportunities.

  • – Establish participatory forums for dialogue and collaboration among stakeholders to promote mutual understanding and equitable resource allocation.

• • Robust monitoring and evaluation:

• • – Institutionalize regular monitoring frameworks to assess the impact of funding changes on service delivery. Incorporate adaptive management theory principles to allow for iterative program adjustments based on real-time data.

The study's conclusions are limited by the small sample size. Future research should employ larger, stratified samples, and longitudinal designs. Incorporating theoretical frameworks like the sustainable livelihoods approach could offer a more comprehensive understanding of funding's impact on community resilience.

This study underscores the substantial impact of diminishing humanitarian funds on the health security of Rohingya refugees and host communities in Cox's Bazar, Bangladesh. Between 2020 and 2023, the decline in financial resources has significantly undermined access to essential services such as nutrition, WASH, and healthcare. The significant reduction in aid has resulted in heightened malnutrition, increased incidence of infectious diseases, compromise in the sectorial standard and the deterioration of healthcare facilities, disproportionately affecting vulnerable communities.

Key findings indicate that global acute malnutrition among refugees has escalated to 15.1%, and the reduction in food rations has contributed to food insecurity for both refugees and host community members. Concurrently, WASH services have been compromised; inability to address the fragile condition (aged facilities) of the WASH facilities leads to inadequate sanitation and water shortages that increase susceptibility to diseases such as acute watery diarrhea and dengue. Moreover, healthcare services are overwhelmed, with gaps in access to medicine due to limited resources, resulting in significant discrepancies in access to care between refugees and host populations.

The research highlights the critical necessity for sustainable and enduring funding strategies to maintain essential health services and infrastructure. Comprehensive strategies must be implemented to address urgent health issues while fostering social cohesion between refugee and host populations.

Future research is crucial and should focus on:

• (1) The long-term effects of fluctuating humanitarian funding on health and nutrition outcomes.

• (2) The efficacy of integrated WASH and health interventions in resource-constrained settings.

• (3) Opportunities for engaging private sector actors in supporting sustainable humanitarian initiatives.

In the absence of a sustained commitment to address these challenges, the humanitarian crisis in Cox's Bazar is likely to worsen, endangering additional lives. The results emphasize the importance of implementing sustainable measures that enhance resilience and promote collaboration among all stakeholders involved in humanitarian efforts.

I would like to express my heartfelt gratitude to my academic supervisor, Dr Md Touhidul Islam, for his unwavering support, guidance, and encouragement to learn the human security issues. I am also deeply thankful to the program coordinator and all my teachers, whose insights and teachings have greatly enriched my understanding of humanitarian issues. I extend my appreciation to the data enumerators and participants in the study, whose valuable contributions made this research possible. Furthermore, I would like to acknowledge the organizations and individuals who provided secondary data and resources critical to this study. Lastly, I am grateful to Bangladesh University of Professionals and Action Against Hunger for their support in facilitating this research.

No outside funding was used to support this work.

Ethical considerations were paramount throughout the research process. Participants were thoroughly apprised of the study's objectives, methodologies, and potential risks associated with their participation. Informed consent was secured from all individuals involved in the study. To ensure a secure environment for participants to disclose their experiences freely, anonymity and confidentiality were rigorously upheld. All data were anonymized during analysis and reporting to protect participant identities.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.