The conflict in Syria created the foundation for some of the global AHCC reporting systems that exist today. The Syrian context is therefore of particular historical relevance and offers lessons for the development of more robust international reporting in future conflicts.
To establish a basis for a discussion of the results of this study, it is necessary to contextualize the study in relation to two main elements: the global state of reporting on AHCC; and the specific context of Syria, where the data were gathered for this study.
What is required for compliance with international resolutions?
AHCC, when analysed as such, is conceptually and legally complex, and is thus difficult to measure objectively and universally. Perpetrators of AHCC range from individuals and communities to parties to armed conflict. The ICRC Health Care in Danger (HCiD) report (January 2012 to December 2013) indicates that globally only about 31 per cent of AHCC are perpetrated by state forces – 25 per cent by state armed forces and 6 per cent by law enforcement – whereas some 46 per cent are perpetrated by either non-state armed groups or individuals, thus rendering accountability in the eyes of the law a multifaceted and complex matter to govern. A 2017 study compiled for Chatham House by researchers at the London School of Economics and Political Science (LSE) found the sparse evidence that existed on AHCC to be Western-biased – i.e. largely reflecting evidence from a limited group of international organizations rooted in the West. The authors conclude that this evidence could be misleading, as it reflects a partial picture, with data on AHCC incidents only being collected in the locations and during the periods when these organizations are operating. The same study identified the lack of a standard approach to data collection, pointing out that each actor has its own data collection method, which could differ further depending on the purpose for which the data are collected. The study also found that if AHCC data are removed from their context, it is difficult to assess whether incidents of AHCC are isolated or the result of a general approach towards the use of force by parties to a conflict.
Compliance with UNSC Resolution 2286 and WHA65.20 necessitates providing evidence for AHCC incidents through continuous documentation in order to inform health policies, hold perpetrators to account and minimize negative public health impacts in conflict, post-conflict and other emergency settings. The impact of AHCC on health systems and the health of affected populations can be substantial, through the wider effects on health personnel, infrastructure and resources, and there exist few long-term studies on AHCC at the country level. Accordingly, AHCC has been placed on the public health agenda as a significant issue to be considered while developing any relevant policies. Therefore, a better understanding of AHCC is needed. The systematic documentation of AHCC is the first step in the way forward for saving lives in crises, strengthening accountability with respect to IHL, and building a greater future knowledge base on the wider impacts of armed conflict.
Public reporting on AHCC
Over the last decade, there have been increased efforts and interest in documenting and reporting on AHCC on the part of humanitarian and human rights organizations, media outlets, think-tanks and academia. This has brought substantial publicity to AHCC and created the foundation for multilateral measures such as the WHA and UNSC resolutions. Human Rights Watch (HRW) and Physicians for Human Rights (PHR) have been consistently reporting on AHCC since the 1980s, while UN human rights institutions and commissions have played a role through a case-based approach. However, no overarching registry of AHCC incidents has been created. The UN Children’s Fund (UNICEF) Monitoring and Reporting Mechanism (MRM) on grave violations of children’s rights in situations of armed conflict was the first UN-led effort for a broader documentation of human rights abuses affecting women and children. It was established in 2005 by UNSC Resolution 1612 to collect and report data on six different violations. While attacks on hospitals which had detrimental effects on children were covered under one of these six categories (‘Attacks against schools or hospitals’), the MRM did not focus on attacks against healthcare as a separate category.
High-profile humanitarian aid agencies have played a key role in focusing more attention on AHCC through advocacy and campaigning. Aiming to provide evidence in order to advocate for bringing an end to this form of brutality and in some instances to hold perpetrators accountable, humanitarian actors have been collecting data and have documented some AHCC incidents in various ways, according to their organization’s objectives. While this data collection has not been universal in scope, and has drawn from different standards, it has been successful in casting greater light on the issue and putting it on the international agenda. The major campaigns and initiatives that have been set up for this purpose are: the ICRC’s HCiD initiative, Medical Care Under Fire by MSF and the Safeguarding Health in Conflict coalition.
The ICRC’s HCiD initiative
While the ICRC has long been positioned as a neutral humanitarian responder and the custodian of IHL, promoting adherence to IHL in a multifaceted way, it has only relatively recently conducted public campaigns specifically related to AHCC. The ICRC-led HCiD initiative was a four-year research and advocacy project launched with the intent of improving practice in the delivery of healthcare in emergencies, the mobilization of a community of concern and the generation of a broader evidence base around AHCC. Between 2011 and 2014, the HCiD published three reports analysing violent incidents affecting healthcare in countries where the ICRC is operational. The methodology of the publications was variable, reflecting the objectives of each study, and while the creation of a global standard in data collection was outside the scope of this initiative, it was successful in the creation of a broader dialogue related to policy and creating a broader community of concern.
The Safeguarding Health in Conflict coalition
Safeguarding Health in Conflict is a coalition of 43 member organizations, including international and national NGOs, academic institutions and human rights organizations. Its objective is to raise awareness on AHCC, strengthen the documentation of these incidents, increase accountability for perpetrators and empower local actors to play a key role in this process. It has published multiple reports that focus on AHCC in particular contexts, as well as annual reports that present compilations of global data. As the coalition encompasses a broad range of agencies, it has access to various sources of both primary and secondary data, such as the Insecurity Insights data from the Security in Numbers Database (SiND), PHR data and primary data from responders. As such, the coalition does not have its own reporting mechanism, but its method draws on various datasets, publicly available records and reports and agency-reported incidents.
WHO’s SSA
The most ambitious ongoing initiative for reporting on AHCC was prompted by the WHA’s passing of resolution WHA65.20, which called for WHO leadership in collecting and disseminating AHCC data in complex humanitarian emergencies. As the Global Health Cluster lead, WHO assumed this role, drawing initially from non-verified secondary data to produce the Attacks on Health Care Dashboard, which was launched in 2014. The dashboard aimed to highlight the scale of the problem and to inform health policies in humanitarian crises. WHO continued to report on this dashboard until 2018, when it was fully replaced by the SSA. Since its initial efforts in 2014, WHO has been developing a broader systematic data collection mechanism to fulfil the requirement of WHA65.20. This new product – the SSA – was launched officially in December 2017. Its purpose is to systematically collect and make available data on attacks on healthcare, and their immediate impact on healthcare in countries facing emergencies. The SSA aims to capture the nature and extent of AHCC, to produce and share reliable data on AHCC, and, learning from the patterns of violence, to better protect healthcare through implementing risk mitigation measures and resilience strategies.
The SSA’s purpose is to systematically collect and make available data on attacks on healthcare, and their immediate impact in countries facing emergencies.
The SSA does not aim to collect data on AHCC for legal use to bring perpetrators of AHCC to justice, as WHO considers this to be outside of its mandate. Instead, the SSA takes a more technical approach to document AHCC focused on accessibility and availability of healthcare for populations affected by conflicts. That said, the SSA makes some of its data accessible to all interested parties who might use it for prosecution and other legal purposes. Considering the sensitivity of this data, only a few data points are shared publicly (number of attacks, number of deaths and injuries and type of attack). Other more sensitive data, such as the location and names of affected facilities, require consent from SSA partners before sharing. As the publicly shared dataset does not include specific information that can help identify perpetrators, it does not play an active role in promoting IHL compliance and accountability, but is available for use in advocacy and research.
After it was piloted, the scaling and refinement of the SSA followed a series of principles that took account of contextual sensitivity, accuracy, timeliness, standardization and transparency. It paid special attention to safety and ethics to fully enshrine the principle of do no harm, and respected the confidentiality of personal data and medical ethics. Other guiding principles included reliability, simplicity and flexibility.
Data collated in the SSA originate primarily from WHO regional and country offices, in coordination with WHO Headquarters. Each party has clear roles and responsibilities at each level in relation to data collection, verification and the overall supervision and maintenance of the system. SSA partners, including local ministries of health, NGOs and other healthcare providers, are involved in identifying incidents and providing data. Led by WHO, health clusters have a key role in centralizing data collection, thereby rendering information on AHCC a component of the health cluster information standards. While information coming from politically affiliated groups, such as non-state armed groups (NSAGs) and the services they provide is not taken into consideration, the SSA does accept secondary data from human rights organizations, media and news agencies, and legal actors.
In the second half of 2017, the SSA was tested in several conflict locations, including Afghanistan, the Central African Republic, the Palestinian Territories and Syria. Following its official launch in December, its geographical coverage was extended to cover many countries in emergencies. As of April 2021, the SSA reported 797 attacks on healthcare in 2018, 1,029 in 2019 and 323 in 2020 across 17 countries including Afghanistan, Iraq, Libya, Palestine, Syria and Yemen. However, these numbers include both ‘high impact’ attacks such as bombings and ‘lower impact’ ones such as verbal threats. Additionally, having used a standardized mechanism of reporting in all countries, changes in the operational contexts of some countries were partially behind the year-to-year differences in the number of incidents reported.
AHCC in the Syrian conflict
Given the massive scale, shocking brutality and broad media coverage of AHCC incidents, the conflict in Syria has shaped the contemporary dialogue on this topic. Studying lessons learned from AHCC reporting throughout the Syrian conflict helps to ground an understanding of global reporting mechanisms historically, and can help focus efforts to improve reporting on AHCC.
The Syrian conflict began as a civil uprising in March 2011 and rapidly spiralled into a deadly armed conflict, producing some of the most egregious examples of AHCC in modern history. As of June 2021, 600 AHCC incidents had been documented on at least 350 health facilities, killing 930 health workers. The UN, the ICRC and many other organizations denounced violence against healthcare in Syria throughout the war, calling on all parties to the conflict to adhere to IHL., Syria became known as the most dangerous place on earth for healthcare workers, and healthcare itself was said to have been weaponized in flagrant violation of IHL.
Incidents of AHCC emerged as early as 22 March 2011, when a medical doctor, a nurse and an ambulance driver – all clearly identified as healthcare workers – were killed in a raid on the Al Omari Mosque in Daraa by Syrian government forces. Medical workers involved in treating protesters and opponents of President Bashar al-Assad and his regime were also persecuted, detained, tortured and killed. This deliberate targeting of medical staff pushed them to operate from secret field hospitals and underground shelters, which were then also attacked. In 2012, amid the growing conflict, opposition groups gained control over substantial territory and there emerged a separation of health systems between the two sides of the conflict. In opposition-controlled areas from which the Ministry of Health (MoH) based in Damascus had to withdraw, local providers and NGOs established a parallel healthcare system, with ad hoc interventions in these areas where AHCC was a major threat.
The type of AHCC was different in the various areas of control, with the majority of incidents happening in opposition-held areas. In areas controlled by the Syrian government, most AHCC incidents were acts of violence against healthcare personnel, such as kidnapping, detention, torture and killing. In opposition-controlled areas, the majority of AHCC incidents were perpetrated against entire facilities. Health structures were bombed, shelled and even subjected to attack by chemical weapons. Many hospitals were completely or partially destroyed, causing a severe disruption of the health system in these areas, with less than one per cent functionality remaining among former health facilities in governorates such as Idlib, Raqqa and Deir ez-Zor, as reported by WHO in 2014–18.
Areas under the control of the Syrian government were supported by the MoH, local and international NGOs, UN agencies and the Syrian Arab Red Crescent (SARC). Some cross-line medical support to opposition-controlled territories was offered, largely through the SARC.
In opposition-controlled areas, healthcare was delivered mainly through aid organizations and locally organized medical networks. Local health actors – whether NGOs, grassroots organizations, or local authorities – developed their operations rapidly in response to the increased needs resulting from the conflict and the MoH’s collapse. Prominent examples of local NGOs working in the health sector are diaspora organizations such as the Syrian American Medical Society (SAMS) and the Union of Medical and Relief Organizations (UOSSM), which supported local health networks to run hospitals and strengthen the health system.
Support was delivered via cross-border operations from neighbouring countries and humanitarian hubs supported the ensemble of health actors. These hubs included Damascus, Gaziantep (in southern Turkey), Beirut (Lebanon), Amman (Jordan) and one in northeast Syria, managed via Erbil in the Kurdistan region of Iraq. In some areas NSAGs were the main healthcare providers: a clear example of this is the health provision in the territories under the control of Islamic State (ISIS).
Although attacks on healthcare facilities have been ongoing since the beginning of the conflict, the establishment of a standardized approach towards monitoring AHCC incidents took shape only in 2016. Human rights actors collected AHCC data from the onset of the war and health responders engaged in 2014 as the scale of incidents increased dramatically. By the summer of 2015, the WHO-led health cluster based in Gaziantep had piloted the Monitoring Violence against Healthcare (MVH) reporting tool, which drew data from health cluster partners with field operations, which were thus primary witnesses to any AHCC incidents. The MVH tool was eventually replaced in March 2018 by WHO’s SSA.
