A better shared understanding of the rules of IHL on medical care in armed conflict is an important foundation, but does not of itself translate into better protection. What is urgently needed is compliance.
Compliance with the rules of IHL concerned with medical care in armed conflict requires that belligerents and other actors take steps to respect – and ensure respect for – the law. Promoting compliance requires the adoption of measures to facilitate implementation of the law, and to prevent violations in the first place. It also requires measures of accountability if violations occur.
6.1 Prevention
6.1.1 States and organized armed groups
As far as prevention of violations is concerned, the preceding chapters have identified various measures that states can take, including, most notably, ensuring that the rules protecting medical care are integrated in military doctrine, policies, directives and operating procedures; and spelling out very clearly the prohibitions and the precautionary measures that must be taken when carrying out military operations that can adversely impact the continuity of the provision of medical care. These measures should be elaborated in peacetime so that they can be disseminated and included in training programmes.
It is not just armed forces that have a role to play. Other ministries and departments also have specific responsibilities, in particular those that recognize and authorize medical facilities, assign medical personnel and supervise the use of the distinctive emblem. There must be clarity as to which ministries have this responsibility. They must adopt clear instructions indicating the measures that they expect to be taken by those operating the facilities and transports, and those overseeing medical personnel, to ensure their protected status is not abused.
Equally importantly – but apparently overlooked in practice – IHL assigns these authorities a key role in supervising the functioning of the facilities, and in intervening when third parties are abusing their protections. This role must be discharged.
The same holds true for the parts of government that are responsible for authorizing the use of the distinctive emblem. Their role in supervising its use in times of armed conflict, and in intervening in cases of alleged abuse, has also been overlooked in practice.
States have other responsibilities, too. For example, they should ensure that domestic law does not allow the punishment of those who provide medical assistance. This can be done by including safeguards in criminal law, including in counterterrorism measures, expressly excluding the provision of medical care from offences. When the adoption of exceptions in the law is not feasible, clear prosecutorial guidance to this effect should be issued and flowed down to those investigating alleged crimes.
Ideally, organized armed groups should adopt measures that have a similar effect.
6.1.2 Those operating medical establishments
Public authorities and organizations that operate medical establishments and transports should adopt internal policies and procedures that allow them to minimize the risk of abuse. They should also adopt procedures for reacting to misuse, should it occur.
6.1.3 The United Nations
The international community –in particular the UN system – has developed numerous tools and processes to promote compliance with IHL.
Despite the centrality of the protection of medical care to IHL, and its importance in assisting some of the most vulnerable in armed conflict, there are no dedicated work streams that focus on this topic. It is, however, considered in other mechanisms. In addition to the mechanisms mentioned below, a number of the fact-finding bodies established by the UN Human Rights Council have also addressed the protection of medical care.
6.1.3.1 Monitoring and Reporting Mechanism on children in armed conflict
Attacks on hospitals are one of the six grave violations monitored by the UN Monitoring and Reporting Mechanism on Grave Violations against Children in Situations of Armed Conflict. For monitoring and reporting purposes, this mechanism adopts a very broad definition of ‘attacks’ as acts that put at risk the integrity of hospitals and medical personnel, and children seeking medical care.
The mechanism also foresees the listing, in the annual report of the secretary-general on children and armed conflict, of parties to a conflict that conduct recurrent attacks on hospitals, or recurrent attacks or threats ‘against protected persons in relation to’ hospitals. Listed parties are required to develop and implement action plans, with the support of the UN, setting out concrete activities to stop and prevent future attacks on hospitals and protected persons. Since such action plans are confidential, it was not possible, when compiling this research paper, to determine whether they include measures to prevent attacks on hospitals; and, if so, what these are.
The Secretary General’s 2025 report listed five states on this ground: Israel, Myanmar, Russia, Sudan and Syria. It also listed a number of armed groups: the Taliban and ISIL in Afghanistan, two groups in the Central African Republic (CAR), five in the Democratic Republic of the Congo (DRC), one in Haiti, and Al-Shabaab in Somalia.
6.1.3.2 Security Council Resolution 2286 (2016)
In 2016 the Security Council unanimously adopted Resolution 2286, on the protection of the wounded and sick, and medical and humanitarian personnel. The resolution, co-sponsored by 84 states, was a strong reaffirmation of the rules protecting medical care in armed conflict.
The resolution is complemented by recommendations by the secretary-general on measures to prevent acts of violence against the wounded and sick, medical and humanitarian personnel, their transport and equipment, and health facilities; and to better ensure accountability and enhance their protection.
Resolution 2286 requires the secretary-general to report annually on this issue. This has been done in the annual report on protection of civilians. While it is only possible to devote a limited section of that report to the topic, it is a valuable way of keeping it on the Security Council’s agenda.
In Resolution 2286, the Security Council also expressed its intention to ensure that peace operations are mandated, ‘where appropriate and on a case-by-case basis’, to contribute to a secure environment to enable the delivery of medical assistance. To date, this has not happened.
6.1.3.3 Sanctions
Conducting attacks against hospitals is a basis for listing people and groups under the Security Council sanctions regimes in relation to Somalia, the DRC and South Sudan. CAR sanctions include the additional ground of attacks against medical personnel.
Conduct violating the protections afforded to medical establishments and personnel is also implicitly covered in those sanctions regimes where violations of IHL more generally are a listing criterion: Sudan, Libya and Yemen.
While sanctions can play a role in promoting compliance with IHL, consideration must also be given to their possible adverse impact on the continuity of provision of medical care. Sanctions should include safeguards authorizing otherwise prohibited conduct when this is necessary to conduct medical activities.
6.1.4 Geneva Call
The NGO Geneva Call works with organized armed groups to promote their compliance with IHL. One way it does this is by encouraging such groups to sign ‘deeds of commitment’ on specific aspects of IHL. These are public pledges by the groups to comply with key humanitarian norms.
In 2018 Geneva Call launched a deed of commitment for the protection of healthcare in armed conflict. Five armed groups have signed this deed so far.
6.1.5 Data collection initiatives
In recent decades a number of initiatives have been launched to collect data on the impact of hostilities on the provision of medical care. They include the World Health Organization’s (WHO) Surveillance System for Attacks on Health Care, developed as part of the organization’s Attacks on Health Care initiative; and Insecurity Insight’s programme of mapping and annual reporting.
Both initiatives adopt very broad approaches as to what constitutes an ‘attack’. For the Insecurity Insight system, for example, an attack is any act or threat of verbal or physical violence, or obstruction that interferes with the availability, access and delivery of curative or preventive health services carried out by an actor linked to the conflict.
It is useful to have an idea of trends. But to address any problematic conduct, it must be identified accurately. The measures needed to prevent the recurrence of looting of medical supplies, for instance, are very different from those necessary to address disproportionate attacks or restrictions on the supply of medical goods and equipment.
6.1.6 Global Initiative to Galvanize Political Commitment to International Humanitarian Law
The protection of hospitals is one of the seven thematic workstreams in the Global Initiative to Galvanize Political Commitment to International Humanitarian Law, launched by the ICRC and six states (Brazil, China, France, Jordan, Kazakhstan and South Africa) in 2024.
Under the initiative, states and experts will examine the main contours of the specific protection granted to hospitals under IHL, and address legal and operational challenges that threaten to undermine this protection. Recommendations from the consultations are due to be presented in late 2026.
6.2 Accountability
6.2.1 Criminal investigations
Violation of some of the rules specifically protecting medical establishments, transports and personnel are grave breaches and war crimes under the ICC Statute, including: directing attacks against hospitals and places where the sick and wounded are collected; directing attacks against buildings, material, medical units and transports, and personnel using the distinctive emblems of the Geneva Conventions in conformity with international law; making improper use of the distinctive emblems of the Geneva Conventions, resulting in death or serious personal injury; and killing or wounding treacherously individuals belonging to the hostile nation or army.
In addition, violations of the general rules regulating military operations, which include protection for medical establishments, transports and healthcare providers, constitute grave breaches and war crimes under the ICC Statute. These include: directing attacks against civilian objects; launching an attack in the knowledge that it will cause incidental loss of life or injury to civilians or damage to civilian objects which would be clearly excessive in relation to the concrete and direct overall military advantage anticipated; and destroying or seizing the enemy’s property unless such destruction or seizure is imperatively demanded by the necessities of war.
Despite such range of possible bases for prosecutions, and the apparent multitude of instances when the rules protecting medical care have been violated, there have been very few criminal investigations and prosecutions by domestic or international courts.
Attacks against hospitals were considered in two cases before the International Criminal Tribunal for the former Yugoslavia, but the court did not charge these as separate offences in either case. So far, it is only the ICC trial chamber in The Prosecutor v. Bosco Ntaganda that has specifically addressed charges of conduct against medical facilities in any detail. The defendant was found guilty of pillage in relation to the looting of medicines and medical equipment from a hospital by soldiers; and for directing attacks against protected objects in relation to an attack against a healthcare facility.
Several factors may have contributed to the paucity of case law. Among them are the challenges of investigating some of the violations, especially those relating to the conduct of hostilities. For example, determining whether a facility was directly targeted requires carrying out retrospective assessments of competing claims of whether the facility was used in a manner that led to loss of protection. In many instances, damage to medical facilities takes the form of incidental damage from attacks against military objectives, but the war crime of ‘disproportionate attacks’ is notoriously difficult to prosecute.
This does not explain the lack of investigation of violations of the absolute rules such as murder or ill treatment of healthcare providers, or looting of medical supplies, equipment and ambulances.
Domestic courts have not been more active. Two recent examples come from Ukraine: Ukrainian prosecutors are investigating a number of Russian attacks on medical facilities, including strikes against hospitals in Kherson and Kyiv.
UN Security Council Resolution 2286 urged states to investigate violations of IHL relating to the protection of the wounded and sick, medical personnel and facilities. A decade on, medical care is simply not a priority area of investigation.
6.2.2 Administrative investigations
One key aspect of accountability that is frequently overlooked is armed forces’ investigations of particular incidents or of systemic issues. Investigations of possible violations of IHL are critical for the proper application of the law, and for discharging the obligation to ensure respect for IHL. While they will not inevitably lead to individual accountability, investigations can identify shortcomings in existing military policies and procedures, and should lead to their improvement.
A case in point is the US Department of Defense’s investigation of the 2015 attack on an MSF hospital in Khunduz, Afghanistan, in which 42 MSF staff and patients were killed. This led the department to revise its targeting standard operating procedures,and to adopt administrative sanctions against some of the personnel involved in the attack.
Administrative investigations can also lead to criminal investigations. At the time of writing, however, there have been no recent instances when such investigations have led to prosecutions for incidents relating to medical facilities or transports.
6.3 Humanitarian arrangements to facilitate the provision of medical care
In addition to measures to promote compliance with the law, practical arrangements can play an important role in facilitating the provision of medical care. These include mechanisms for notifying belligerents of the location of medical facilities and movements of transports; and arrangements like temporary cessations of hostilities and the establishment of humanitarian corridors. These can allow patients, healthcare personnel and medical supplies and equipment to reach medical establishments, and medical transports to operate. Evacuations can facilitate the movement of the wounded and sick from areas of active hostilities. More ambitiously, belligerents could agree the establishment of hospital zones.
These arrangements can enhance the security of the wounded and sick, facilitate their access to medical care and the functioning of medical facilities. With the notable exception of ‘days of tranquillity’ – i.e. temporary suspensions of hostilities to undertake specific tasks, frequently vaccinations – such arrangements have been established on very few occasions. For them to operate in a manner that is safe for the intended beneficiaries, the arrangements must be established by agreement between the warring parties. Reaching agreement has proved extremely difficult. As is the case for other issues addressed in this paper, an intermediary can play a key role in facilitating agreement, but in most recent conflicts it has been impossible to find a party that is willing to assume this function and that is acceptable to all belligerents.
6.4 Good practice
- Initiatives to track the adverse impact of military operations on medical care should identify the nature of the conduct in a specific manner, rather than referring to all conduct as ‘attacks’.
- In setting the mandate of peace operations, the UN Security Council should incorporate contributing to a secure environment to enable the delivery of medical assistance, as called for in Resolution 2286. The Department of Peace Operations should elaborate policies and practices for this aspect of peace operations.
- Armed forces should adopt minimum standards for the conduct of effective and independent investigations; and should conduct internal investigations following specific incidents when military operations have serious consequences on the capacity of medical facilities to operate, or where their impact on the continuity of medical care appears to be a systemic problem. The outcome of such investigations should indicate whether relevant doctrines and procedures must be amended.
- Armed forces should ensure their doctrines and procedures address the forces’ roles in agreeing and implementing humanitarian arrangements for the benefit of the wounded and sick.
- Organized armed groups should elaborate and implement similar measures to the those outlined in the two preceding points.
