This article examines the impact of the use of explosive weapons in populated areas on healthcare access and explores strategies to implement relevant commitments in the Political Declaration, including inclusive healthcare delivery, empowering local actors, and promoting cross-sectoral collaboration. It underscores the need for coordinated advocacy, innovative healthcare solutions, and sustainable funding to address the direct and indirect effects of the use of explosive weapons on civilians and health systems and services.
Introduction
The escalation of conflict in recent years has placed healthcare access in fragile and conflict-affected regions at the forefront of humanitarian concerns. Attacks on healthcare personnel, hospitals, and other vital infrastructure have surged, severely undermining the ability to provide life-saving medical care to civilians in need. In conflict-affected areas, these challenges are magnified by the targeting of healthcare workers, the destruction of medical infrastructure, and significant logistical barriers.
The adoption of the Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences of the Use of Explosive Weapons in Populated Areas in 2022 raised hopes that there would be a significant shift in addressing these challenges. The Declaration provides a framework for states to strengthen the protection of civilians in armed conflict, including healthcare workers and facilities. However, despite the international recognition of these issues, the situation in affected areas has continued to deteriorate, particularly in high-intensity conflict areas such as Gaza, Sudan, Syria and Ukraine.
Throughout 2024, the humanitarian community witnessed a staggering increase in attacks on healthcare workers, with over 1,850 reported incidents of violence against health personnel and medical facilities. These attacks not only claim the lives of medical workers but also lead to the collapse of healthcare systems, leaving already vulnerable populations without access to critical services and unable to realise their right to health. This growing crisis underscores the urgency of coordinated action to address the many barriers that prevent healthcare from reaching those in dire need.
To support the effective implementation of the Political Declaration, a multi-stakeholder process was launched in early 2024. Through a series of six collaborative workshops, this initiative engages states and their armed forces, as well as other relevant stakeholders – including the International Committee of the Red Cross, international organisations, humanitarian operators, survivors and civil society. On November 12-13, Humanity & Inclusion - Handicap International, a co-founding member of the International Network on Explosive Weapons (INEW) hosted a workshop in Belgium to develop an agenda for action to strengthen healthcare access in contexts where explosive weapons are widely used.
Addressing the barriers to healthcare access
EWIPA use disproportionately affects the availability, accessibility, and quality of healthcare services both in the short and longer term due to both the direct and indirect or reverberating impacts of explosive weapon attacks on healthcare. This severely compromises or prevents affected populations from accessing medical care and treatment at a time when both EWIPA specific and other health needs increase exponentially. This is especially the case for rehabilitation and mental health and psychosocial support services (MHPSS) despite staggering levels of needs. Intersecting identities such as age, gender, and disability also shape the experience of specific groups. Women, children, persons with disabilities and older persons in their diversity therefore face heightened barriers to accessing healthcarewhen health services are wiped out, out of reach, diverted or at breaking point.
Attacks on healthcare workers and facilities
One of the most glaring issues is the rising number of attacks on healthcare workers and medical facilities. These attacks, which have escalated significantly over the last few years, are not only a direct violation of international humanitarian law but also a clear indication of the increasing dangers faced by those working in healthcare settings in conflict zones. Hospitals and clinics, once considered neutral ground, are increasingly targeted by state armed forces and non-state armed groups, leaving healthcare professionals at risk and denying medical care to the civilian population. This targeted violence results in a direct breakdown of essential medical services, further exacerbating the suffering of people caught in conflict. In 2024 alone, more than 1,143 healthcare facilities were either damaged or destroyed as a result of direct attacks, with many health workers killed or injured while attempting to treat the wounded.
Logistical and administrative barriers
Beyond the immediate threats to safety, logistical and administrative barriers also complicate the delivery of healthcare in conflict zones. The destruction of roads, bridges, and other critical infrastructure severely limits the ability of medical teams to reach those in need. In areas where explosive weapons have been deployed, the damage to transport networks and vital infrastructure often makes it nearly impossible to deliver supplies or deploy healthcare teams to affected regions. Furthermore, bureaucratic obstacles such as delays in securing approval for medical shipments and restrictions on the movement of aid workers create significant challenges for timely and efficient healthcare delivery.
Funding gaps for local healthcare workers
In addition to these challenges, one of the most pressing issues is the funding gap for security measures aimed at protecting local healthcare workers. While international organizations often receive substantial funding for medical supplies, infrastructure, and logistical operations, far less is allocated to ensuring the safety of healthcare workers, particularly local staff. Local healthcare workers are frequently on the front lines of conflict, and without the appropriate security resources and measures, they are at great risk of harm. Despite the crucial role they play in the delivery of medical care, local healthcare workers are often underfunded, unsupported, and left vulnerable to violence and exploitation.
Lack of coordination between actors
Another critical factor in the healthcare access crisis is the lack of effective coordination between humanitarian organizations, local governments, and armed groups. Effective communication and collaboration are essential to ensuring the safety of healthcare workers and improving the delivery of medical services in conflict zones. Unfortunately, in many cases, there is a lack of coordination between these parties, leading to confusion, miscommunication, and delays that hinder the efficient and safe delivery of healthcare.
Lack of compliance with international humanitarian law
Finally, the implementation of international humanitarian law (IHL) remains inconsistent and inadequate. While there are clear legal frameworks in place to protect healthcare workers and facilities during armed conflict, these laws are not always respected or enforced. The absence of accountability for violations of IHL means that perpetrators are rarely held responsible, creating a dangerous environment for healthcare providers and other humanitarian workers. The failure to uphold international law has led to a situation where healthcare workers are routinely exposed to violence and threats, without adequate legal recourse.
Different types of approaches and strategies have been used by health workers, humanitarians, states, diplomats, advocates and researchers to strengthen civilians’ access to healthcare in EWIPA settings. They have done so by adopting practical and innovative adaptation measures, tools; alternative models of healthcare delivery; developing guidance to strengthen collaboration and coordination; generating compelling evidence on the effects of EWIPA use on healthcare and harmonising data collection and dissemination efforts; advocating for greater action and political leadership, including to foster the implementation of the Political Declaration’s commitments on victim assistance in the context of healthcare access in EWIPA settings. There are opportunities to increase collaborative efforts, strengthen synergies between advocacy agendas and across sectors, and learn from existing and related initiatives, such as the 2015 Safe School Declaration - Global Coalition to Protect Education from Attack (GCPEA) and the Children in Armed Conflict (CAAC) agenda.
Agenda for Action: Strengthening Healthcare Access in Conflict Zones
Given the severity of the situation, the workshop participants identified several key actions that must be taken to protect healthcare access and ensure the safety of healthcare workers in conflict zones. These actions focus on improving security, strengthening legal frameworks, and enhancing coordination between humanitarian actors, armed groups, and governments.
One of the first steps in strengthening healthcare access is ensuring the safety and protection of healthcare workers and medical facilities. It is critical that both international and national actors uphold their obligations under international humanitarian law to prevent the targeting of healthcare workers and infrastructure. Governments and armed groups must commit to respecting the neutrality and inviolability of medical facilities, ensuring that healthcare workers are not only able to carry out their duties but are also able to do so without fear of violence. In regions where explosive weapons are deployed, specific measures must be taken to prevent collateral damage to healthcare infrastructure and personnel. These could include the use of deconfliction mechanisms, where parties to the conflict agree not to target healthcare facilities and workers.
Additionally, a more coordinated and effective approach to healthcare delivery in conflict zones is essential. This includes improving logistics and infrastructure so that medical supplies and personnel can reach affected populations quickly and efficiently. The international community must invest in the rebuilding and protection of critical healthcare infrastructure, including hospitals and clinics. Ensuring that roads, transport routes, and supply chains are safe from attack is critical to maintaining an effective medical response during conflict.
Furthermore, the funding and capacity gap for healthcare workers' safety must be addressed. Local healthcare providers often face the greatest risks in conflict zones, yet they are also the most vulnerable due to the lack of security measures in place to protect them. Donors must allocate resources and develop capacity for the protection of local medical staff, providing them with the training, equipment, and support they need to work in dangerous environments. Ensuring the safety of local healthcare workers is vital to sustaining medical operations in conflict zones, as they are often the ones who continue to work when international staff are evacuated or unable to access affected areas.
Another key element in the agenda for action is strengthening the legal frameworks surrounding healthcare access in conflict zones. International humanitarian law must be consistently applied and enforced to ensure that healthcare workers and facilities are protected during armed conflict. Mechanisms for holding perpetrators accountable for violations of international law must be strengthened, ensuring that those who target healthcare workers are held accountable for their actions. This will require increased political will from states and the international community to uphold the principles of international law and ensure that healthcare access is protected during times of conflict.
Finally, there is a need to foster stronger coordination and learning between humanitarian organizations, governments, and armed groups. Open and effective communication between these parties is essential for ensuring the safety of healthcare workers and the efficient delivery of medical aid. Humanitarian organizations must engage in proactive dialogue with all parties to the conflict, including non-state actors, to establish clear and mutually agreed-upon frameworks for safe medical operations. At the same time, governments and armed groups must be held accountable for their actions and encouraged to respect the principles of neutrality and impartiality in conflict zones.
Conclusion
Access to healthcare in conflict zones remains one of the most pressing humanitarian issues of our time. The impacts of conflict, targeting of healthcare workers and facilities, compounded by logistical, security, and bureaucratic barriers, has led to a dire situation for civilians in conflict-affected areas. The Political Declaration represents an important step forward, but stronger commitments and concrete actions are needed to ensure its full implementation.