Armed conflicts, whether international or non-international, create a profound humanitarian crisis that severely disrupts access to essential health services. In these volatile environments, health care professionals, facilities, and patients face grave dangers, ranging from indiscriminate attacks and forced displacements to resource shortages and the collapse of public health infrastructure.
International humanitarian law (IHL) seeks to mitigate these effects by safeguarding the provision of medical care, even amidst hostilities. However, compliance remains inconsistent, and violations are rampant.
This article examines the legal framework governing health care during armed conflict, the challenges faced by health professionals, and the urgent need for stronger implementation of existing norms and mechanisms of accountability.
Legal Framework: Protection of Health Care Under International Law
1. Geneva Conventions and Additional Protocols
The cornerstone of health care protection in armed conflict lies in the Geneva Conventions of 1949 and their Additional Protocols of 1977.
- Geneva Convention I focuses on the care for wounded and sick soldiers on land.
- Geneva Convention II extends these protections to warfare at sea.
- Geneva Convention IV ensures the protection of civilians, including medical personnel and facilities.
- Additional Protocol I (AP I) (Article 12–16) expands the protection to include health workers, medical transports, and hospitals in international armed conflicts.
- Additional Protocol II (AP II) extends similar protections to non-international armed conflicts.
These provisions prohibit attacks on medical units, personnel, and transports and mandate that the wounded and sick be collected and cared for without adverse distinction.
2. Customary International Humanitarian Law
Customary IHL, as codified by the International Committee of the Red Cross (ICRC), reinforces these treaty obligations. Rule 25, for example, emphasises the protection of medical personnel, while Rule 28 addresses medical units, and Rule 29 concerns medical transports.
3. Human Rights Law and Other Legal Instruments
International human rights law (IHRL), especially the International Covenant on Economic, Social and Cultural Rights (ICESCR), affirms the right to the highest attainable standard of health. Even during conflict, derogations must not undermine the core obligations of non-discrimination and basic health care access.
Attacks on Health Care: A Persistent Crisis
Despite clear legal prohibitions, attacks on health infrastructure are alarmingly frequent.
1. Intentional Targeting and Collateral Damage
Health facilities are often deliberately targeted to demoralise civilian populations or to deny care to enemy combatants. For instance, in Syria, airstrikes on hospitals became a systematic strategy, with numerous attacks documented by Physicians for Human Rights.
2. Denial of Access and Blockades
Sieges and blockades in conflict zones often restrict the delivery of essential medical supplies. The blockade of Yemen by coalition forces led to catastrophic humanitarian consequences, including a resurgence of cholera.
3. Weaponisation of Health Services
In some conflicts, control over health care has been weaponised—either by denying care to populations aligned with adversaries or by manipulating aid as leverage.
WHO Confirms Record Attacks on Ukraine’s Health System
According to the World Health Organisation (WHO), over 1,000 verified attacks on Ukraine’s healthcare system have occurred since the full-scale war began, marking the highest ever recorded in any humanitarian crisis. By 2023, 1,067 incidents were confirmed, including 952 attacks on medical facilities, injuries to 74 health workers and 27 patients, and damage to 124 medical vehicles.
Challenges in Delivering Health Care During Conflict
1. Lack of Safety for Medical Personnel
Health workers face threats not only from direct attacks but also from abductions, intimidation, and reprisals for treating alleged enemies. The ICRC’s “Health Care in Danger” initiative has highlighted how these threats deter local and international medical workers from operating in conflict zones.
2. Collapse of Health Infrastructure
Conflict-induced displacement, destruction of facilities, and disruptions in supply chains often lead to a collapse of entire health systems. Essential services such as maternal care, vaccinations, and emergency surgeries become unavailable.
3. Discrimination and Inequity in Health Access
Certain groups—ethnic minorities, refugees, and prisoners—may face disproportionate barriers to accessing health care during conflict, aggravating pre-existing vulnerabilities.
Legal Obligations of Parties to the Conflict
Under IHL, both state and non-state actors are bound to:
- Respect and protect health care workers, facilities, and patients.
- Ensure access to impartial humanitarian aid.
- Refrain from using medical units for military purposes (which forfeits their protection).
- Allow and facilitate the rapid and unimpeded passage of medical supplies.
These obligations are non-derogable and apply equally in both international and non-international armed conflicts.
Role of International Organisations
1. International Committee of the Red Cross (ICRC)
The ICRC plays a critical role in conflict zones by:
- Providing emergency medical aid.
- Facilitating the evacuation of the wounded.
- Promoting compliance with IHL through confidential dialogue with belligerents.
Its Health Care in Danger project has produced essential guidelines for protecting medical services during war.
2. World Health Organisation (WHO)
The WHO tracks attacks on health care and assists in strengthening health system resilience in conflict-prone areas. Its Surveillance System for Attacks on Health Care (SSA) is a key tool in data collection and advocacy.
3. United Nations Security Council
Resolution 2286 (2016) condemned attacks on health care in conflict and urged Member States to comply with IHL. However, the lack of enforcement mechanisms has undermined its effectiveness.
4. United Nations and Human Rights Council
UN bodies investigate and report on IHL violations. They can recommend sanctions, refer cases to the ICC, or set up commissions of inquiry.
Ensuring Accountability and Redress
1. International Criminal Law
Attacks on health care may constitute war crimes under the Rome Statute of the International Criminal Court (ICC). Articles 8(2)(b)(ix) and 8(2)(e)(ii) criminalise intentionally directing attacks against hospitals and medical personnel in both international and non-international armed conflicts.
2. Universal Jurisdiction and Domestic Enforcement
States may prosecute such crimes under universal jurisdiction, even when they occur abroad. Several European countries have initiated cases against individuals responsible for targeting health facilities in Syria and other conflict zones.
3. Need for Stronger Implementation
Despite existing laws, enforcement remains weak. Enhancing mechanisms for documentation, investigation, and prosecution is critical for deterring future violations.
Recommendations and Way Forward
1. Strengthening Legal Compliance
- Mandatory IHL training for armed forces and non-state actors.
- Integration of health protection norms into military operational planning.
- Binding commitments from parties to a conflict regarding the neutrality of health care.
2. Enhancing Protection and Infrastructure
- Equipping health facilities with better protective measures (e.g., sharing GPS coordinates with all parties).
- Ensuring redundancy in medical supply chains to handle emergencies.
- Increasing support for local health workers through training and safety protocols.
3. Bolstering International Pressure
- Regular reporting by the UN Secretary-General on health care violations.
- Conditioning military aid and diplomatic recognition on compliance with IHL.
- Expanding funding for WHO and ICRC missions in high-risk regions.
Conclusion
Health care during armed conflict is not a privilege—it is a legal and moral imperative enshrined in international humanitarian law. While the law provides robust protection, the lived realities of war often present a grim contrast. The increasing number of deliberate attacks on health infrastructure highlights a deepening disregard for human life and the sanctity of medical neutrality.
It is imperative that the international community not only reiterates its commitment to IHL but also ensures that violators are held accountable. In protecting health care, we preserve not only lives but also the foundational norms of humanitarianism in warfare.
References
[1] Geneva Conventions (1949) and Additional Protocols (1977)
[2] International Committee of the Red Cross
[3] World Health Organisation – Surveillance System for Attacks on Health Care
[4] Rome Statute of the International Criminal Court
[5] UN Security Council Resolution 2286 (2016)
[6] WHO Press Releases on Ukraine Healthcare Attacks (2023)
