The international community is failing to protect healthcare in armed conflict

Devastating new norm

Following the brutality and chaos of the second world war, the Geneva Conventions of 1949 and its “additional protocols” set international legal standards for protecting non-combatant individuals including civilians, medical staff, wounded and sick soldiers, and aid workers. Parties to conflict have obligations to protect healthcare and to allow health workers to perform their duties without interference.

But in many conflict zones today, healthcare is no longer respected as a neutral entity. Violations of international law are widespread, and without intervention, the erosion of healthcare protections is fast becoming the new norm.

While the number of incidents reported attracts attention, their implications don’t always come under the spotlight. Attacks on healthcare destroy more than infrastructure; they deny people their universally recognised right to health by disrupting essential services, undermining the trust in health systems, and worsening the suffering of already vulnerable populations. For example, in 16 conflict zones assessed by WHO, 17% of health facilities were damaged and 19% of health facilities were either partially functional or non-functional. In Gaza today, only 17 of 36 hospitals (47%) are partially functional.2 In Khartoum, only 12% of 815 health facilities are at least partially functional.2 In Afghanistan and Pakistan—the two remaining countries where polio is endemic—efforts at eradication have been severely constrained by deliberate targeting of health workers, resulting in serious immunisation gaps. 2

Culture of impunity

The erosion of protections for healthcare in conflict zones represents a serious failure of global governance, stemming from a lack of effective diplomatic efforts, legal enforcement, and accountability mechanisms. International responses have largely been limited to public condemnation, with few tangible steps towards deterrence of attacks. Although data collection, reporting, and advocacy are essential, they are insufficient alone.

Because of the failures to prevent or deter attacks, frontline health workers and communities are forced to find their own ways to mitigate attacks on healthcare. They do this by, for example, decentralising service delivery, reinforcing the physical infrastructure of health facilities, developing contingency plans for relocation of healthcare, and training staff on emergency procedures. This is an unjust responsibility to lay on health workers, who are often already working under extreme circumstances. Protection of healthcare is our collective responsibility.

Way forward

The challenge now is how to reset and strengthen existing mechanisms and reaffirm a collective commitment to uphold the right to health and the principles of international humanitarian law—including the protection of healthcare—in armed conflict. The In the Line of Fire report lays out a series of clear recommendations to prevent and mitigate attacks on healthcare in armed conflict.

At global level, the report calls for the establishment of a global alliance for the protection of healthcare in conflict comprised of committed member states, UN agencies, and international, non-governmental, and civil society organisations. The alliance would leverage political, diplomatic, and legal mechanisms to promote greater respect for international humanitarian law and to advocate for greater accountability. The report proposes the establishment of a special rapporteur on the protection of healthcare in armed conflict to monitor and report on attacks and to facilitate advocacy and cooperation on safeguarding health. Intensified diplomatic efforts are also urged, including valid accountability mechanisms and the exercise of universal jurisdiction. Improved data collection, verification, and sharing is also vital.

At the national level, governments are encouraged to build capacities of healthcare professionals on health and humanitarian diplomacy. They should also redouble efforts to train military personnel on their obligations under international humanitarian law and integrate humanitarian and human rights law into secondary and tertiary education, and to develop relevant policies and laws to enshrine respect for the right to health and humanitarian law. In conflict zones, special attention must be paid to responding to physical and psychological trauma among health workers.

At local level, protection of healthcare should become integral to health and humanitarian programming. This includes ensuring that emergency response plans contain options for service continuity in the context of attacks on healthcare and potential health system disruption. Increased engagement of communities in the protection of healthcare is another vital measure.

Not one single actor or organisation can ensure the protection of healthcare in conflict alone. Political leaders, judicial bodies, the global health community, policy makers, civil society, and others must move beyond words and actively protect healthcare in conflict zones. The stakes are too high to ignore; protecting healthcare in conflict is a legal obligation and moral imperative.