In the Line of Fire: Protecting Health in Armed Conflict

"Among the most stark examples of the impact that AHC [attacks on healthcare] have on public health are the threats that they pose to the global eradication of polio and the dramatically reduced access to healthcare in Gaza..."

The imperative to protect healthcare in conflict settings is enshrined in international humanitarian law (IHL), enacted through humanitarian principles ensuring that medical personnel, facilities, and transports are safeguarded, and provide care without discrimination. Despite these legal protections, there has been a rise in attacks against health care (AHC) that severely disrupt vital health services and leave vulnerable populations without essential care. The central question this report seeks to address is how do we reset the balance and reaffirm the way forward to uphold the fundamental tenets of IHL, press for greater action to end impunity, and foster greater political support to create structures that will ensure the protection of health systems and civilians during war.

After an introduction, Section 2 provides a brief overview of current trends in global conflict. It then examines the scale, nature, and trends of AHC and their impact on health service delivery. Several illustrative case studies are provided. For example, the reader learns that, in recent years, there has been a noticeable decline in attacks targeting polio workers. Workers in security-compromised areas of Pakistan continue to face threats by militants. In these regions, the Government of Pakistan implemented special strategies to deploy security personnel to safeguard polio teams. However, militant groups in these areas have now shifted their focus to targeting law enforcement personnel. During polio vaccination campaigns, security personnel guarding the polio vaccination teams have come under attack. Vaccination campaigns can be disrupted by such attacks, leaving thousands of children unvaccinated, and allowing the virus to continue circulating.

As noted here, there are many mechanisms that collect data and provide analysis and information on AHC. However, none have succeeded in providing a global and comprehensive database. "[A]dvocacy and/or accountability mechanisms are impossible without effective surveillance and evidence generation."

Section 3 explains the existing protective mechanisms for healthcare in armed conflict and includes an overview of legal frameworks and norms. To cite only one example: States that have relationships with state or non-state armed groups can exert their influence through private communications, diplomatic channels, and public condemnations.

Options for mainstreaming protection of healthcare into health and humanitarian programmes are presented. A key starting point is a contextual analysis, which will inform the understanding of the specific risks that healthcare systems face in conflict zones. This analysis should include identifying key actors, their motivations, and potential threats to healthcare services. Stakeholder mapping helps identify all relevant parties, including belligerents, local communities, and international organisations, so that their perspectives and influence on the healthcare system can be understood.

This section of the report also explores approaches to scaling up advocacy and diplomacy. Here are some examples:
 

• Capacity building empowers staff to articulate the value of health care as a common good, understand their rights and responsibilities, and actively participate in their own protection. The training should emphasise medical ethics, underscoring the protective value of the trust established between healthcare providers and the community. This ethical foundation, combined with knowledge of IHL and humanitarian principles, can help healthcare personnel to advocate effectively for the protection of civilians, the wounded and the sick, while clearly communicating the duties and responsibilities of armed actors.
• Engaging with both state and non-state armed actors is crucial to ensure the protection of healthcare in conflict zones. This engagement should include education on the right to health, the impartiality of medical care, and the obligations of all parties to protect medical personnel, facilities and patients. Also, creating clear communication channels between healthcare providers and armed actors can help mitigate misunderstandings and reduce the risk of attacks on healthcare facilities.
• Raising awareness among local communities about the importance of protecting health care is a vital component of advocacy and the overall protection of the healthcare system. Community involvement can range from participating in the design and implementation of healthcare programmes to taking active roles in disseminating key messages and establishing early warning systems. Community engagement can be fostered through participatory programmes that involve local leaders and influencers in advocating for the understanding and protection of health care as a common good. Public campaigns can educate communities on their rights under IHL and the consequences of attacking healthcare facilities. These campaigns should use local languages and culturally appropriate messaging to ensure broad understanding and support.
• Diplomatic efforts are essential to ensure that all parties in a conflict adhere to international standards for the protection of health care. These efforts include engaging states committed to IHL to actively use diplomatic leverage to protect healthcare in conflict settings and to advocate for greater compliance and accountability. International collaboration is also crucial. Coalitions of civil society organisations play an increasingly important role in advocating for the protection of health care in conflict zones. Through research, reporting, and strategic advocacy, these coalitions can amplify the voices of affected communities, call for accountability and compliance with IHL, and encourage policy changes.
• Effective strategic communication is important in influencing stakeholders and mobilising international support for healthcare protection. This approach includes the use of data, case studies, and testimonies to build a compelling narrative that resonates with legal experts and the general public. Strategic communication should leverage high-profile figures, international organisations, and media platforms to amplify the message globally. Communication should also ensure the widespread understanding and prioritisation of healthcare protection in conflict zones.

Section 4 presents key preventative, mitigating, and accountability policy recommendations to consider. One example: Increase community engagement in protecting health care. Community members can be associated with AHC from several perspectives - they can be the victims (for example, through loss of access to health services resulting from an attack), the perpetrators, or the protectors (as advocates and negotiators). Communities play a central role in the response to and resolution of all health and humanitarian emergencies. Strong and open community engagement can mitigate the risks of community members being victims and perpetrators of AHC, while also engaging them as forceful contributors to the protection of health care.

Section 5 outlines the report's conclusions. In brief: "To protect the right to health and healthcare effectively, we must implement comprehensive strategies that:
 

• strengthen accountability mechanisms.
• enhance awareness of international humanitarian law and the right to health.
• build resilience and preparedness.
• foster improved engagement, advocacy and diplomacy.

The recommendations in this report...provide a strategic framework to guide policymakers, human rights organizations, Member States and UN [United Nations] agencies on future action. By adhering to these guidelines, these actors can play a pivotal role in enhancing the protection of healthcare amid armed conflict. They can also ensure that future interventions are effective and enduring for years to come."