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Background: Over the past 20 years, attention to sexual violence in humanitarian crises, along with resources directed to addressing it, have grown. Despite this, recent humanitarian assessments and evaluations reveal that clinical management of rape (CMoR) services lag behind, established minimum standards are rarely if ever met, and humanitarian actors do not prioritise these services. This lack of services places survivors of sexual violence at risk, and contributes to low reporting rates. In 2005, the humanitarian system introduced reforms including the establishment of the Cluster Approach to coordination along with emphasis on lead agency accountability for sectoral responses.Aim: This qualitative inductive study explored availability of CMoR services and accountability for gaps under the humanitarian clusters in Liberia 2006-2007 and Democratic Republic of Congo 2008-2009. It aimed to identify causal factors for gaps in availability of CMoR services.Methodology and Methods: A feminist constructivist approach was applied to data collection and analysis. Semi-structured interviews with 35 key informants were triangulated and supplemented by review of documentation produced by humanitarian agencies. NVivo 11 was used for coding and to assist with analysis of data. A feminist institutionalist lens was applied to an analysis of the interplay of formal and informal institutions in the humanitarian system. Results: Inadequate CMoR services characterized both case studies. These gaps were attributed to a lack of human, material and economic resources, a causal factor identified also by prior research. Key informants identified three factors that contributed to de-prioritising humanitarian CMoR services: 1) informal institutions in the humanitarian system 2) the framing of sexual violence as a security and justice rather than health issue and 3) gendered biases in the humanitarian system.Conclusion: The persistence of gaps in availability of clinical management of rape services and the lack of accountability for these gaps in the humanitarian system suggest that resource constraints are insufficient explanatory factors. Additional research is needed to identify the roles of informal institutions and gendered biases in the system and issue framing in humanitarian responses. A focus on building national capacities may contribute to addressing these gaps but may be affected by similar biases.