This month marks the third anniversary of the unanimous adoption by the UN Security Council of Resolution 2286, which condemns attacks on health care and demands that UN member states ensure the protection of health care delivery during conflicts.
The resolution addresses attacks against the wounded and sick; medical personnel and humanitarian personnel exclusively engaged in medical duties; their means of transport and equipment; and hospitals and other medical facilities in armed conflicts. It calls on all parties to conflicts to fully comply with their obligations under international laws to ensure health care delivery is protected.
In August the same year, the UN secretary general submitted his recommendations on measures to operationalize the resolution.
The recommendations echoed those of other existing campaigns, calling for adhering to international treaties, establishing domestic accountability mechanisms that include independent investigations and prosecution, developing national protection legislation, raising awareness among armed groups and forces, better documentation of these attacks and more cooperation between humanitarian organizations and affected communities.
The recommendations also called on the United Nations to collect, verify and analyse data on the problem.
The resolution provides a strong framework for states and other parties to conflicts to take measures to protect health care. It helped to solidify international efforts that had preceded it and boosted the visibility of the issue.
Reporting and documentation of incidents of violence has improved, and the World Health Organization has established the Surveillance System for Attacks on Health Care as a platform for bringing such information together. In 2018, its first year of operation, this surveillance system documented 717 attacks on health care across nine conflict zones and 233 in the first four months of 2019.
But despite the resolution and the secretary general’s recommendations, there is little indication that the levels of violence are reducing, and in some corners of the world, they appear to be increasing. According to Physicians for Human Rights, which has systematically collected information on this since 2011, the period that followed the adoption of the resolution was the most dangerous to health workers in Syria. It documented 35 attacks in July and August 2018 alone and an increase in attacks of almost 50% from 2017 to 2018.
Meanwhile, South Sudan experienced a particularly high level of violence against health facilities during May–September 2016, with large-scale destruction and looting of health facilities in the Equatoria region.
Ebola health workers and facilities continue to be attacked in the Democratic Republic of Congo (DRC). Similarly, vaccinators and vaccination facilities are being attacked in Afghanistan. Severe restrictions on the entry of commercial and humanitarian goods into Hodeidah Port in Yemen and the blockade of the Gaza strip in Palestine have interrupted medical supply chains.
This pattern of attacks against health care facilities, workers, transport and supplies continues to be one of the major challenges facing the delivery of health care in conflict zones. It is causing hundreds of thousands of civilians to be deprived of access to health care and weakening the response to outbreaks. Moreover, it is contributing to mass displacement to areas with safer and accessible health services.
International-level action needed to drive prosecutions
Resolution 2286 is not legally binding and calls for action primarily by member states. This has contributed to inadequate demonstrable commitment to the implementation of its recommendations. States have been slow in developing protection regulations. Furthermore, many of them have themselves been involved in attacks against health care.
Therefore, their cooperation in establishing domestic accountability mechanisms and on ending the impunity of perpetrators has been slow or non-existent. So far, not a single independent investigation has been carried out on attacks against health facilities, workers or transport that have been used exclusively for medical purposes, despite the availability of well-documented evidence in some cases.
Translating Resolution 2286 into practice requires action not only from member states but also from international bodies. The prosecution of perpetrators is an important starting point. This should begin with the Security Council initiating independent investigations and drawing on the expertise of the International Humanitarian Fact-Finding Commission.
The secretary general should also establish fact-finding mechanisms to consider such situations, including in non-international conflicts. Independent investigations could have a deterrent effect and would be the base for further international (such as by the International Criminal Court) and national legal action.
Implement bottom-up approaches
Although the resolution and the secretary general’s recommendations set a baseline of what should be done by states, they fail to link the global response to the challenges faced on the ground and do not pay enough attention to the need to engage local health care providers in the planning and implementation of protection measures. Both lack an explicit call for international support to and collaboration with local health providers and civil society actors who bear most of the burden of violence.
Local actors are most often the most knowledgeable about what works best in their contexts, and often find it challenging to convince donors to fund some of the context-specific protection measures they know they need to implement, such as fortification of walls and perimeter fences.
Local actors are also key in delivering accurate information to affected communities to combat disinformation and misinformation-fuelled violence. This has been notably prevalent in Afghanistan, with several deadly attacks against vaccinators, and in the DRC, with a recent eruption of violence against Ebola treatment centres and workers.
The international humanitarian community should use approaches to combat violence against health care that include local health providers in humanitarian planning and policies. It has done this in the wider humanitarian response but has not integrated it into the way it tackles attacks against health care. Sufficient funds should be allocated for the implementation of context-relevant measures that are devised with the participation of the local health care providers.
Making progress in these two areas would help reduce the incidence and impact of attacks on health care in conflict settings.