The increased incidence of attacks on healthcare in recent armed conflicts has prompted the creation of additional international legal frameworks to address the issue. However, systematic mechanisms to document and report attacks on healthcare will need to be developed to ensure compliance.
Since the founding of the International Committee of the Red Cross (ICRC) in 1863, increased attention has been paid to the importance of delivering healthcare during conflict, both to affected civilian populations and to wounded and sick combatants. The First Geneva Convention, signed in 1864, established the basis for the inviolability of medical personnel and establishments in armed conflict between states. This was revised and expanded in 1906, in 1929, and in 1949 after the end of the Second World War. Additional Protocols to the Conventions were developed later, to address non-international conflicts. These conventions, along with the humanitarian principles that were adopted by the Red Cross and Red Crescent Societies and later by the UN General Assembly in 1991,, have been incorporated into international humanitarian law (IHL), a subset of international law that has been in development since 1864. IHL protects those who do not take part in – or are no longer participating in – armed conflict, such as civilians, medical and religious military personnel and wounded combatants. Despite the existence of these broadly endorsed conventions, principles and laws governing the use of force in armed conflict, egregious attacks against healthcare workers and systems remain a feature of contemporary armed conflict.
Attacks on healthcare during conflict (AHCC) thus represent a major obstacle to mounting an effective health response and hinder access to healthcare for populations in conflict settings and fragile states. AHCC broadly include all violent assaults on health facilities, personnel, vehicles and supplies in conflict settings. A 2018 study reviewing attacks on health in the last three decades showed that AHCC has presented a significant challenge in recent conflicts, with 21 incidents being documented in the Bosnian conflict, more than 24 in Chechnya, 12 in Iraq, more than 100 in Kosovo, 93 in Yemen and 315 in Syria. AHCC have a serious impact on health systems and the health of affected populations by reducing the availability, accessibility and functionality of health facilities, personnel and vehicles. A recent report by WHO analysing three years of data, covering 2018–20, from the SSA found that health personnel were the most frequently affected health resource and that attacks on healthcare were associated with higher rates of deaths in 2020 than in the previous two years. However, lack of evidence, along with other factors related to a lack of effective mechanisms to ensure compliance, is still promoting an absence of accountability on the part of perpetrators, at both international and local levels.
Following years of advocacy on the part of health and humanitarian responders, the UNSC adopted Resolution 2286 in May 2016 to strengthen the protection of healthcare facilities in conflict settings. The resolution strongly condemns attacks against medical facilities and personnel in conflict situations, and demands that all parties to armed conflict comply fully with their obligations under IHL. In addition, it urges all states and parties to conflicts to develop effective measures to prevent, address and investigate these attacks. It should be noted that UNSC Resolution 2286 was preceded by a resolution adopted by the WHA (WHA65.20) in 2012, which tasked WHO to provide global leadership in developing methods of documenting AHCC.
Thus, compliance with Resolution 2286 necessitates the development of systematic mechanisms to document and report AHCC, even if the form such mechanisms should take is not explicitly dictated in the resolution itself. Systematic documentation of AHCC – which has not hitherto been seen as a specific issue – has in the past proved challenging, as it occurs in an environment unconducive to data collection.
This research paper will use the example of the conflict in Syria to explore the topic of documenting and reporting AHCC, and will extrapolate general conclusions from key informant interviews and a comparative analysis of the output of various documentation mechanisms found in Syria between March 2011 and January 2018.
